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10/27/2017

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ACEP 2017

Cruising the LiteratureCardiology 2017Corey M. Slovis, M.D.

Vanderbilt University Medical CenterMetro Nashville Fire DepartmentNashville International Airport

Nashville, TN

VanderbiltEM.com

Three updates

- Valsalva- Nitroglycerin- Antiarrhythmic Rx for VF

Modified Valsalva

Lancet 2015;386:1747-53

Can lying the patient down and raising their legs 45˚ for 15 seconds immediately post

Valsalva increase its effectiveness?• 428 Patients with PSVT

• Randomized 1:1 for standard vs. modified

• Sitting vs sitting then lie back with legs raised

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15%

Valsalva Effectiveness(n=214 each group)

Standard Lie back, Legs up

47%%

Lancet 2015;386:1747-53

p < 0.0001 or = 4.9

Use new drugs as soon as possible before they develop side effects or

lose efficacy

Am J Emerg Med 2017 online May 27

Is the modified Valsalva really as effective as first reported?

• 56 patients, Turkish single center study

• Std Valsalva vs modified Valsalva

• Narrow complex PSVT up to rate of 220

• Lancet study: 47% effectiveness0

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10.7%

Standard Valsalva Modified Valsalva

42.9%

%

Am J Emerg Med 2017 online May 27

p < 0.007

Modified ValsalvaTake Homes

• Works in almost ½ of patients

• Less need for adenosine

• Efficacy reaffirmed in another study

• This is a practice changing maneuver

Nitroglycerin in AMI

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• 1,466 STEMIs, 56% received NTG

• Montreal Quebec EMS 2010-2012

• Evaluated BP changes in Inf vs Non-Inf AMIs

• BP < 90 or BP > 30mm Hg s/p NTG

Prehosp Emerg Care 2016;20:76-81

How dangerous is NTG in Inferior AMI?

0%

5%

10%

15%

20%

25%

STEMI BP Changes Post NTGPrehosp Emerg Care 2016;20:76-81

BP < 90 BP > 30mm Hg

8.2

Inf Not-Inf Inf Not-Inf

23.4

P=NS P=NS8.9

23.9

Does the HR predict BP in chest pain pts treated with nitroglycerin?

• 10,308 pts from Montreal EMS

• 20% of pts (2,057) were tachycardic pre-NTG

• NTG dose was 0.4 mg spray

• NTG repeated Q5 if CP persisted

• 3.1% of all pts developed hypotension s/p NTG


0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

2.9%

NTG and Hypotension

WNL HR


3.9%

HR

35%

P=0.02

decreased by 36% for every 10 mm Hg of systolic BP

Above 100 mm Hg

Probability of Hypotension NTG and Hypotension

Take Homes

• Inferior and Anterior AMI hypotension equal

• Beware borderline BPs

• Especially if the pt is tachycardic

• EMS and hospital personnel should be prepared for BP especially in those who are tachycardic, regardless of Inf AMI or Ant AMI

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Amiodarone in VF

• 3,026 pts., 10 ROC sites

• Randomized, double blind, placebo controlled

• VF/pVT, s/p 1 or more shocks, s/p epi

• Only adult medical VF/pVT OOH

New Engl J Med 2016; 374:1711-22

What is the best antiarrhythmic for shock resistant VF/pVT:

Amiodarone vs Lidocaine vs Placebo?

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30 24.4 23.7

Survival to DischargeNeurologic Outcome

Survival

2118.8

New Engl J Med 2016; 374:1711-22

%

A PL A

17.516.6

Mod Rankin ≤ 3

L P

• 7 studies: 3 RCTs, 4 non-RCTs

• 3,877 pts in RCTs and 700 in non-RCTs

• Includes 2016 NEJM trial

• Admission and Discharged Alive evaluated

Resuscitation 2016;107:31-7

What do all studies combined tell us about Amiodarone vs Lidocaine in VF/pVT?

ResultsAmiodarone vs Placebo:

- trend for hospital discharge with Amio (p=0.08)

- No difference in favorable neuro outcomes

Lidocaine vs Placebo:- No significant difference at discharge

Amiodarone vs Lidocaine:- No difference in hospital discharge (p=0.81)


Amiodarone vs Lidocaine vs PlaceboTake Homes

• There is no strong evidence on antiarrhythmic efficacy in VF/pVT

• If 3% superiority of Amiodarone over placebo was true difference (requires larger study) then 1,800 lives would be saved in North America yearly

• The data is not conclusive

• The drugs are given 10-20+ minutes into arrest

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At the present time, there is no clear benefit of Amiodarone vs Lidocaine

Late in VF it’s not clear either drug is beneficial

• 5% absolute improvement of Amiodarone over placebo (p ≤ 0.04) if arrest witnessed (1,934 pts)

• 21.9% absolute increase in hospital discharge in Amiodarone vs placebo if EMS witnessed and gave drugs near immediately (p < 0.01 for 154 pts)

NEJM 2016:375;801-3

Authors Note in Letter to Editor

Ischemic Warnings by ECG

• Atypical CP is seen with AMI

• So are “atypical” ECGs with STEMI and ACS

• 5 ECG patterns to look for

• Left main equivalent, Posterior AMI

• AVL ST in Inf AMI, T Wave V1 > V6, Wellen’s

West J Med 2017;18:601-06

West J Emerg Med 2017;18:601-6

Left Main Equivalent AVR with diffuse ST depression Left Main Proximal or LAD Occlusion

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R > ST ↑

ST ↓

Posterior AMI

Posterior AMI


T Wave Inversion in AVLClue for Inferior AMI


Broad T Wave V1 – V2 > V5 – V6Early Anterior AMI

Wellen’s WarningCritical Stenosis of LAD

Epinephrine in Cardiac Arrest

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Circulation 2015:132 (suppl 2);5444-64

Standard dose epinephrine (1 mg Q 3-5 minutes) may be reasonable for patients

with cardiac arrest (class 11b)

Epinephrine Use

• Early administration may improve ROSC and neurologic outcomes – later administration may decrease both

Am J Emerg Med 2017;35:676-80

Does timing of epinephrine affect neurologic outcome in cardiac arrest?

• 13,326 pts, retrospective Japanese database

• 2011-2014 data; divided pts into 2 groups

• 8 min from 911 to arrival and 8-16 min from 911

• Evaluated if epi given within 10 min of arrival

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1.4

Early or Late EpiGood Neuro Outcome at 1 Month

Am J Emerg Med 2017;35:676-80

911 to PT < 8 min 911 to PT 8-16 min

6.0

Epi ≤ 10 Epi ≥ 10 Epi ≤ 10 Epi ≥ 10

4.2

Epi in CPRTake Homes

• Epinephrine’s role in CPR still not clear

• ROSC and good neuro outcomes are improved when epi is given early in CPR versus later

• Give early in arrest to optimize good outcome

• 2,974 VF/pVT arrests, 1,510 with epi < 2 min

• Inpatient data from 300 GWTG-R hospitals

• Propensity matched cardiac arrest pts

• Compared epi before vs after 2nd shock

BMJ 2016;353:1577-87

Does giving epinephrine before 2nd shock help or hinder resuscitation?

• 51% of patients received epi before 2nd shock

• 87% of both groups received 2nd defib

• Groups equal for total defibrillations (3)

• Early epi group received 3 mgs of epi on average vs 1 mg in later dosing

• Similar TOR times (22 vs 21 mins)

BMJ 2016;353:1577-87

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8067%

79%

Epi Before vs After 2nd Shock

ROSC

31%

48%

BMJ 2016;353:1577-87

%

< 2 < 2> 2 min > 2 min

25%

41%

Good Neuro

< 2 > 2 min

Survival

All p < 0.001

Wait for second shock before administering epinephrine in VF

Epi for VFTake Homes

How often should epinephrine be dosed in cardiac arrest?

AHA-ACC ACLS Guidelines state Q 3-5 min


Does dosing interval of epinephrine affect survival in CPR?

• 20,909 adult pts, 505 GWTG hospitals

• Looked at survival vs dosing interval

• Adjusted via multi-variate analysis

• Most common intervals were 4-5 and 5-6 min

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1.25

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1.75

2.00

2.25

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2.75

3.00

5-6

0.780.96

Epinephrine Dosing Intervals (min)Adjusted Odds Ratio for Survival

1-3 3-4


1

4-5

OR

6-7 7-8 8-9 9-10

0.96

1.41 1.30

1.79

2.17


Does spacing out epinephrine more than PALS/ACLS recommends affect pediatric

CPR outcomes?

• 1,630 pediatric in-hospital arrests

• Intervals of 1-5, 5-8 min and 8-10 min evaluated

• Multi-variate analysis used to control co-morbidities

• Separately analyzed vasopressor use pre-arrest

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1.0

1.99

Epinephrine Dosing Intervals (min)Adjusted Odds Ratio for Survival

1-5 5-8


2.67

8-10

Epinephrine Dosing IntervalTake Homes

• Although ACLS guideline say Q 3-5, it appears that spacing epinephrine doses out to up to 8-10 minutes may be optimal

• This is a violation of current guidelines

• No randomized study exists

• Give less epinephrine not more

Epi in CPRSummary

• Give ASAP

• Wait for second shock if VF

• Space dosing intervals longer

Bicarbonate in CPR


How does bicarbonate administration during CPR affect outcome?

• 15,601 OOH cardiac arrests Vancouver

• 5,165 (37%) received IV bicarbonate

• Evaluated survival and good neuro outcome

• Also performed propensity scoring comparisons 0123456789

1011121314

12.3%

10.8%

Bicarb vs No BicarbUnadjusted, Unmatched


Survival Good Neuro

1.6%

Bicarb No Bicarb Bicarb No Bicarb

%

1.3%

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Adjustment via propensity analysis required, as patients getting

bicarbonate usually are in arrest longer with refractory arrests and higher total doses of epinephrine

Bicarbonate in Cardiac ArrestResuscitation 2017;119:63-9

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.03.5%

2.8%

Bicarb vs No BicarbPropensity Analysis


Survival Good Neuro

2.2%

Bicarb No Bicarb Bicarb No Bicarb

%

OR=0.64 OR=0.59

1.8%

Bicarbonate in Cardiac ArrestsTake Homes

• Don’t routinely use

• Decreases survival and favorable neuro

• Generates CO2 and is hyperosmolar

• Use for pre-existing acidosis or OD(DKA, sepsis, methanol, EG, TCA)

• Great in Hyperkalemia


How much better is IO vs IV medication administration in cardiac arrest?

• 1,800 pts from King County (not Seattle)

• Retrospective review 2012-2014

• 1,525 IV vs 275 tibial IO patients

• Evaluated ROSC, hospital admit and D/C

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6052.9

42.3

IV vs IO Multivariate Analysis

ROSC

47.2

37.7


IV IVIO IO

19.113.6

Discharged

IV IO

Hospital Admit

P=0.02

P=0.06

P=0.56

IV vs IO in CPRTake Homes

• No proven benefit to IO over IV

• But this is not a randomized trial

• Although “factored in”, early IV is likely significantly better than later IO

• IO might be the rescue access in arrest

• We need a good study-this is the only one out there though

10/27/2017

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VFib

Refractory VFib

• Move pads from Ant-Lat to Ant-Post

• Consider Beta Blockade

• Consider Double Sequential Defibrillation (DSD)

• ECMO


Is double sequential defibrillation (DSD) beneficial in refractory VF/pVT?

• 45 patients treated with DSD

• Retrospective observational study

• London Ambulance Service

• Compared to 175 who got standard defibrillation

• Only patients with ≥ 6 shocks compared

• 3 standard Ant-Lat defibrillations

• Anti-arrhythmic administration

• 3 standard Ant-Post defibrillations

• Double sequential defibrillation

• Done 3 – 4 seconds apart

Double Sequential ProtocolResuscitation 2017;117:97-101

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35%38%

Standard vs DSD in VF/pVT

EMS ROSC

56%59%


%

STD STDDSD DSD

6.6% 7%

Discharged

STD DSD

Hosp ROSC

Double Sequential DefibrillationTake Homes

• Not a randomized trial

• Many pts got up to 10 shocks pre DSD

• The role of Double Sequential Defibrillation is not yet clarified and needs a randomized larger trial

What about if they convert?

• Systematic review and meta-analysis

• 11 articles involving 2,885 pts.

• STEMI pts 13 x for transport to CCL

• Evaluated STEMI in CCL if no ST AMI on ECG


Is PCI indicated s/p VF/pVT arrests if no STEMI on 12-lead?


• 71.9% of pts with STEMI on ECG had an acute culprit lesion

• 32.2% of pts with no STEMI on ECG had an acute culprit lesion

PCI improves survival by 30% even if no STEMI on ECG

Immediate CCL s/p VF/pVT Arrest

PCI s/p VF improves survival by a factor of 3.7 regardless of STEMI or no STEMI on ECG


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VF/pVT Arrests on CCLTake Homes


• Another in a series of studies

• All show CCL improves survival

• All show up to 30% of “no STEMI” is a STEMI

• Go to the lab s/p VF/VT


How common is an intervenable coronary lesion in pts who obtain ROSC s/p arrest from a

non-shockable rhythm?

• 1,396 ROSC pts, 18 centers, retrospective review

• 879 of ROSC pts had AS or PEA

• 141 underwent angiography (44 had a STEMI)

• 97 pts c ROSC s/p AS or PEA without ST AMI went on to angiography

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100

97 pts.

Incidence of Intervenable Lesion at PCIs/p ROSC c AS or PEA – No STEMI on ECG

Total Pts PCI

24.7%

%


PCI s/p ArrestTake Homes

• If cardiac etiology suspected, even patients without shockable rhythms can go to the CCL

• STEMI s/p arrest is not required to have an intervenable lesion

• About 1/3 VF/VT arrests with ROSC but no “STEMI” have an acutely intervenable lesion

PCI s/p ArrestTake Homes

• A surprising number of presumed cardiac etiology AS and PEA may also benefit from PCI

• Very controversial, be very selective in choosing s/p AS/PEA CCL candidates

Advanced Airways in Cardiac Arrest

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Should we be intubating children in cardiac arrest?

• Inpatient study, 2,294 pts, 1,555 intubated

• GWTG Registry Hospitals; 2/3 ED or ICU

• Median age: 7 months

• 75% were 21 days – 4 years old; 90% witnessed

• Used matched non-ETI controls

JAMA 2016;316:1786-97

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4536%

41%

To Intubate or Not

Survival

30%

42%

JAMA 2016;316:1786-97

%

ETI ETINo No

14%17%

No Pulse FavorableNeuro D/C

ETI No

Pulse FavorableNeuro D/C

RR=0.89

Peds Intubation During Arrest• Another bag more, intubate less

• No improved survival with ETI, maybe less

• Most children were witnessed arrests, in EDs & ICUs

• The less kids you routinely intubate, the less you should try

• 108,079 Adult pts, 668 GWTH hospitals

• Matched intubated vs non-intubated pts min by min

• Used 43,314 ETI vs no-ETI matched pts over 15 min

• Evaluated ROSC, survival and good neuro outcomes

JAMA 2017;317:494-506

Should adults in cardiac arrest be intubated early?

0%

10%

20%

30%

40%

50%

60%

ROSC/Survival Matched Outcomes ETI vs No ETI

JAMA 2017;317:494-506

ROSC Survival

59.3%

RR0.97

RR0.8419.4% 16.3%

57.3%

No ETI No ETIETI ETI 0%

2%

4%

6%

8%

10%

12%

14%

16%

Neuro Matched Outcomes ETI vs No ETI

JAMA 2017;317:494-506

Good Neuro

13.6%

RR0.78

10.6%

No ETI ETI

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• Intubation decreased absolute survival and good neuro outcome by 3%

• This is a 22% relative reduction in good neuro outcomes at discharge

• Biggest difference was in shockable rhythm32% relative decrease in good neuro

ETI in Adult Cardiac ArrestTake Homes

Focus on timely defibrillation and high quality CPR!

HEART ScoreChest Pain

High Sensitivity Troponin• Pathway for early ED D/C

• Troponins at 0 and 3 hours

• Used HEART Score

Circulation: Cardiovasc Qual Outcomes 2015;8:195-203

The HEART Score

H History

E ECG

A Age

R Risk Factors

T Troponin

MD Calc for HEART Score

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It is safe to discharge patients if their

HEART Score is 3 or less (≤ 3)

Patients with HEART Scores above 3 (≥ 4)

should undergo stress testing and/or admission

Simplicity of the HEART Score

• 12 centers, 1,040 ED pts, used Roche hs TnT

• Compared HS ≤ 3 vs HS > 3

• Did both a 0 and ∆ 1 hr R/O protocol

• And a 0, 1, 2, 4-14 hr R/O protocol

Circ Cardiovasc Qual Outcomes 2017;10:e003101

Can a HEART Score ≤ 3 and a 0 and 1 hour deltahigh-sensitivity Troponin be used in an effective rapid rule out ACS protocol? TRAPID-AMI trial

• A HEART score ≤ 3+

• 0 hour hs Troponin T < 14+

• 1 hour ∆ Troponin < 3

Key Finding

Equates to a 30 day Death / AMI risk of 0.2%

Am J Emerg Med 2017;35:704-9

Is “Low Risk” by HEART and other scoring systems really low risk?

• 434 pts from 7 EDs

• Average age 57 (49-64)

• Used HEART, TIMI, GRACE, EDACS

• Compared HEART ≤ 3 vs ≤ 2

HEART ≤ 3 has a miss rate of 3.6%

HEART ≤ 2 had a miss rate of 0

Am J Emerg Med 2017;35:704-9

OK, so now that HEART is “clearly” the way to work up chest pain –

what is T-MACS?

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• Troponin-only Manchester ACS decision aid

• Uses a single hs Troponin plus 6 variables

• ECG ischemia; SBP < 100 on arrival

• Sweating; vomiting; pain to R arm or shoulder

• Worsening or crescendo angina(Prior T-MACS studies used heart-type fatty acid binding protein)

Emerg Med J 2017;34:349-56

Sensitivity and NPV of T-MACS1,459 pts

• 98.1% sensitivity for ACS, 98.8% for AMI

• 40% of CP pts were “very low risk”

• NPV: 99.9% for ACS, 99.7% for AMI

• Some false negative had CP < 1 hr prior to ED arrival

• Used hs Trop T; less sensitive than hs Trop I

Emerg Med J 2017;34:349-56

High Sensitivity Troponins • 4 different Troponin testing protocols

• Level of detection vs abnormal vs 2 delta protocols

Circulation 2017;135:1597-1611

A single Troponin can miss up to 6% of AMIs if CP began within 2 hours of ED arrival

An undetectable Troponin I level (LOD < 2 ng/L) in patients with CP for at least 2-3 hours rules out AMI

with 100% sensitivity

Circulation 2017;135:1597-1611

Circ 2017;135:1586-96

• High-STEACS study of 1,218 pts.

• ARCHITECT hs Trop I limit of detection is 1.2 ng/L

• Compares European guidelines to high STEACS< 99th percentile at 0 and at 3h or 6h(16 ng/L Female and 34 ng/L Male)

• STEACS: < 5 ng/L at 0 hrs and 3 hr ∆ < 3 ng/L

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Circ 2017;135:1586-96

• The lower the Troponin value used for abnormal, the more sensitive your rule out will be

• Using the 99th percentile increases missed AMIs by 90% compared to a lower cut-off value

(18 acute misses vs 2)

• Using lower value is 99.5% sensitive

Annals Int Med 2017;166:715-24

Does a single undetectable hs Trop T rule out AMI?

• Collaborative meta-analysis

• 9,241 pts, 11 studies

• Non-ischemic ECGs + hs Trop T < 0.005 ug/L

• Had 2,825 of these low risk pts

Annals Int Med 2017;166:715-24

• Single undetectable hs Trop may miss some pts

• 50% of misses (false negatives) seen within 3 hrs

• Some studies 100% accurate

• Two “outliers” missed > 10%

• Overall 98.7% accurate(30d MACE 98%)

Take Homes onHigh Sensitivity Troponins

• Undetectable at 0-1 or 0-3 rules out AMI

• Delta testing excludes evolving AMI

• Early AMI presenters need values over time

• Using the 99th percentile may not be optimal

hs Troponin testing with Objective Scoring is synergistic

At the current time there is no universally accepted high sensitivity

Troponin protocol and objective scoring system that is “proven” to be optimal

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Expert HS Troponin Knowledge2017-2018

• Troponin = myocardial stress/infarction

• No Troponin > a little > a lot of Troponin

• 3 values: None; “Normal”; Elevated

• Normal is abnormal

• Delta Troponin essential if CP ≤ 2-3 hrs

JACC 2017;70:2226-36

• 19,460 CP pts followed 3.5 yrs (± 1.2)

• Strong graded relationship of Trop to:MI, HF, CV death and overall mortality

JACC 2017;70:2226-36

Any detectable Troponin is undesirableLess than the 99th percentile is still bad…

All important decisions are made onincomplete information….

Yet we are responsible for everydecision we make.

Sheldon Kopp 1972

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BMJ 2016;355:i6165

Does shared decision making affect the ultimate care of ED CP patients?

• Multicenter randomized trial, 898 CP pts

• 6 US EDs; 1:1 randomization, low risk pts

• Randomized to decision aid or not

• Measured pt knowledge, uncertainty, trust in MD

• Compared % admitted for testing & adverse events0

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Management Differences Using Shared Decision Tool

BMJ 2016;355:i6165

Admit to OBS for Testing 30 d Stress Test

52.1

Usual Care Decision Aid Usual Care Decision Aid

Less Obs admits and less stress testing when patients actively involved in

shared decision making

Greater knowledge of their risk and lower decisional conflict scores over

their care.BMJ 2016;355:i6165

So what should you do:

- Do a very careful history

- Use HEART but diaphoresis &/or radiationto R arm or shoulder, Abn ECG = high risk

- Beware a single Troponin

- Be more careful in HS = 3

- Always involve the patient and family

AMIIs fentanyl or morphine superior for

chest pain R/O ACS patients?

• Double blind randomized trial, 187 pts

• Winnipeg EMS in Manitoba Canada

• All patients received ASA and NTG patch

• Fentanyl or morphine given if pain continued

• 5 mg morphine Q5 vs 50 mcg fentanyl Q5


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• No difference in pain relief

• No statistical difference in nausea or emesis

• But: more nausea (18% vs 12%) and 2x emesis (2:1)

Results

• Hypotension seen with morphine, not fentanyl5/99 vs 0/88 (p = 0.06)

Take Homes

• Fentanyl much less likely to cause hypotension

• Histamine release with morphine may be culprit

• Unclear if Fentanyl causes less nausea and vomiting

• Morphine may be associated with increase in infarct size and mortality in AMI

• Switch to Fentanyl if you haven’t already

• 6,629 Swedish R/O AMI pts (75% STEMI)

• Had to have ischemic ECG or positive Troponin

• 6 L O2 open mask vs room air

• 1 year follow up

• Only pts with O2 sat ≥ 90%

New Engl J Med 2017;377:1240-49

Is oxygen effective in AMI?

Oxygen Therapy in AMI

• May increase coronary vasoconstriction

• May increase infarct size

• May increase free radical formation

• May increase heart rate

Average O2 Saturations

• 99% with O2

New Engl J Med 2017;377:1240-49

• 97% without O2

0%

1%

2%

3%

4%

5%

6%

6 L O2 vs Room Air Mortality and Re-Admits for AMI

New Engl J Med 2017;377:1240-49

Mortality Re-Admit AMI

5.1%

RA O2 RA O2

3.0%

3.8%

5.0%

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1.9%

Hypoxemia Requiring Supplemental O2

O2 No O2

New Engl J Med 2017;377:1240-49

7.7%%

P < 0.001

Oxygen for AMITake Homes

• No benefit for high flow face mask at 6 L

• No in infarct size with O2(Troponin 946 vs 983)

• But almost 1 in 10 on RA may get hypoxic

• Why not 2 L by nasal cannula?

AFib• 1,091 pts, mean age 63.9 years, 2010-2012

• 6 academic centers, 84.7% AFib, 15.3% Aflutter

• Clear history of onset ≤ 18 hrs

• Clear 7d history + no thrombus by TEE

Ann Emerg Med 2017;69:562-71

Is Canadian “aggressive care” with cardioversion effective and safe?

Cardioversion Effectiveness

• 52.2% successful medical conversion

• 90.0% successful electrical conversion

- Mean max energy 148 joules

- 1.4 mean shocks required

Ann Emerg Med 2017;69:562-71

Aggressive Canadian AFib/Flutter RxTake Homes

• Large study with impressive results

• Not so common in USA

• Will likely spur more aggressive US ED care

• Cardiology consulted in only 1/5 cases

• 63% referred to Cards, 42% to Family Practice MD

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MedicationsNOACSNSAIDS

Loperamide

• 5,738 pts from the ORBIT-AF II Registry

• Routine lab evaluation not required with NOACs

• Considered safer than Warfarin

• Some patients require dosing modifications

JACC 2016;68:2597-604

Are we dosing non-vitamin K antagonists correctly?

• 87% being dosed correctly

• 9.4% underdosed

• 3.4% overdosed

• Renal disease was # 1 cause of dosing errors

• More strokes, bleeds, AMIs & hospitalizations

Results JACC 2016;68:2597-604

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All Cause Mortalities

Rec Dose Under dosed

JACC 2016;68:2597-604

8.1

Over dosed

Take HomesNon Vitamin K Oral Anticoagulants

NOACs

• 1 in 8 AF patients are dosed incorrectly

• Under and over dosing increases morbidity and mortality

• Do not discharge patients with renal impairment on a NOAC without working with an ED or hospital pharmacist and/or an AFib focused cardiologist

BMJ 2017;357:J1909

Do NSAIDs increase the risk of AMI?

• Bayesian meta-analysis of 446,763 patients

• 61,460 AMIs analyzed

• 385,303 controls

• Study shows NSAIDs increase risk of AMI

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• Using NSAIDs for 1-7 days increased risk of AMI by about 1.5

• Higher doses increased risk

• Longer than 1 month duration kept risk level constant

NSAID RisksBMJ 2017;357:J1909

Annal Emerg Med 2017;69:73-8

91% increase in Loperamide overdoses reported to Poison Centers from 2010 to 2015• Previously considered a non-abuse safe drug• Inhibits peristaltic activity• Inhibits large bowel u-opioid receptor• Can have opiate-like effects in large doses• Deaths now being reported

• 1 capsule = 2 mgs

• Pts taking 100-500 mgs

• Beware cardiac toxicity

• QT, Heart Block, VT/VF, Asystole

• CNS: lethargy, confusion, seizures

J Emerg Med 2017;53:73-84

Cardiac Toxicity of LoperamideJ Emerg Med 2017;53:73-84

Loperamide ODTake Homes

• Another “new” arrhythmogenic agent

• May require large doses Narcan

• Narcan drip as prolonged course

• Another “anti” drug for Q-T

• Beware delayed toxicity

Prolonged Q-T“Anti” Drugs

• Antibiotics /Antifungals

• Antiemetics

• Antidepressants / Antipsychotics

• Antihistamines

• Antiarrhythmics

• Anti-diarrheal

/ Anti-diarrheal

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PE

J Emerg Med 2017;52:280-85

What are the most common new ECG changes due to PE compared to known

baseline ECGs

• 352 PE pts with prior baseline ECG• New T wave inversions (34.4%)• T wave flattening (29.5%)• Sinus tachycardia (27.3%)• No change (24.1%)• S, Q3 T3 (3.7%)

Inferior T Wave InversionJ Emerg Med 2017;52:280-85

• T wave inversions most common: inf > lat > anterior

• T wave flattening inf > lat > ant

• ¼ of all PE pts had no ECG changes

• S, Q3 T3 rare (< 1/20)

• 560 pts, mean age 76

• 11 Italian hospitals

• Admitted patients only

• All had Wells criteria PE work-ups

• D-dimer performed if not low risk

NEJM 2016;375:1524-31

How common is PE in patients in the ED admitted for syncope?

PE – Syncope Findings

• 1 in 6 (17.3%) of syncope pts had a PE

• 25% of syncope of unknown origin had PE

• PE in 13% of syncope pts with alternative Dx

• Note: only hospitalized pts

• Most had underlying illness or trauma

NEJM 2016;375:1524-31

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A PE workup (D-dimer or CTA) needs to be performed in any patient with

unexplained syncope and all syncope patients who are being admitted

PE and SyncopeInitial Take Homes

So should you really do a pulmonary CTA on all of your PE patients being admitted?

• Meta-analysis of 12 additional studies

• Compared NEJM to 9 ED and 3 IP studies

• 6,608 ED pts with PE and 975 IP pts

Am J Emerg Med 2017;epub September

How common is PE in syncope patients seen in ED and in those requiring admission?

Incidence of PE in Syncope Pts

• NEJM PE prevalence in ED pts: 3.8%

• Pooled prevalence in meta-analysis: 0.8%

Am J Emerg Med 2017;epub September

• NEJM PE prevalence of PE in Admitted pts: 17.3%

• Pooled prevalence in meta-analysis: 1.0%

PE in SyncopeTake Homes

• NEJM high PE incidence is an outlier

• Many criticize study due to selection bias(Many CA pts. High number of insignificant sub segmental PEs, V/Q scanning in 25% of “PE” pts and used wrong n)

• No pts had RV strain on ECG, yet had syncope?

• BP, HR, O2 sat, ECG and history to decide workup

• Use clinical judgement and not NEJM

Lancet 2017;390:289-97

Can a simple to use decision rule be used to R/O PE? The YEARS study

• 3,616 pts, 12 Netherland hospitals

• Prospective study, 13% incidence of PE

• Evaluated efficacy and use of CTPA

• Simplifies Wells and D-dimer decision making

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YEARS Algorithms Lancet 2017;390:289-97

WellsYEARSClinical signs DVTPE most likely Dx

HemoptysisHR > 100

Prior PE, DVTMalignancy

Immobile or surgeryD-dimer > 1000

(over 500 if 1 above positive)

YEARS negative + D-dimer < 1000 mg/ml

Positive YEARS + D-dimer < 500 mg/ml

YEARS ProtocolNo Testing and ED Discharge

Lancet 2017;390:289-97

YEARS Patients

• Average age 53 (± 18)

• 62% female

• HR > 100 in 20%

• Hx of PE or DVT in 10%

• 16% estrogen use in females

• 12% immobilization or surgery past 28 d

YEARS Results

• Absolute 14% decrease in CTPA use for patients under age 50

• 30% relative decrease for total group using YEARS vs Wells and D-dimer of 500

• YEARS missed 0.61% VTEs at 3 mos

• YEARS missed 0.21% fatal PES at 3 mos

Simplified YEARS to R/O PETake Homes

• Study does NOT report if missed pts would have been picked up by Wells or D-dimer


• First trial using YEARS

• Not yet validated

• Not ready for me to switch…yet

J Thromb Haemost 2017;15:1764-69

Can a simplified version of the Geneva Score work well to clarify PE risk?

• 1,621 pts, 19 European hospitals

• Used age adjusted D-dimer

• 3 month follow-up

• Compared Simplified vs Original Geneva Score

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Geneva vs Simplified Geneva ScoreJ Thromb Haemost 2017;15:1764-69

Age > 65 1 1Prior PE/DVT 3 1Surgery or Fx < 1 month 2 1Active malignancy 2 1Unilateral lower limb pain 3 1Hemoptysis 2 1HR 75-94 bpm 3 1HR ≥ 95 bpm 5 2Pain on calf palpation 4 1and unilateral edema

GS SGS

Geneva vs Simplified Geneva ScoreClinical Probability

Geneva Simplified Geneva

Low prob 0-3 0-1

Intermediate 4-10 2-4

High prob ≥ 11 ≥ 5

Simplified GenevaTake Homes

• No loss of sensitivity with simplified scoring…essentially the exact same result

• Age adjusted D-dimer in pts over age 50 decreased CTA by 12% without any in missed PE

• Simplified score is easier to use…but use MDCalc or pre-printed table…neither can be memorized and easily remembered

Am J Emerg Med;35:126-31

Is there a benefit to IV bolus NTG vs constant infusion in HF pts with BP

• 395 pts, retrospective study, Detroit Receiving Hospital

• IV bolus vs IV infusion vs infusion + bolus• Evaluated LOS, ICU admit, morbidity/mortality• Bolus dose median 1-2 mg (1000-2000 ugms)• 79% - 1 dose, 14.6% 2 - doses, 4% - 3 doses

0%

10%

20%

30%

40%

50%

60%

70%

80%

48%

67%

ICU Admission with NTG

Bolus Infusion


79%

Combo

P=0.006

0

1

2

3

4

5

6

7

8

4.4

6.3

Length of Stay

Bolus Infusion


7.3

Combo

P=0.01

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IV NTGBolus vs Infusion

No difference in complications

No difference in hypotension

No difference in need for ETI

Take Homes on NTG

• Be careful interpreting results

• Compares 1000-2000 mg vs infusion starting at median 20 ugm titrated to 60 ugm

• Be very, very aggressive if using infusions –aim for 100 ugm 1 min

• Be very, very careful with bolus – start at 0.25-0.50 mg (250 ugm-500ugm)

Summary

Modified Valsalva works in almost 1/2

Summary

NTG causes hypotension, beware HR/ BP

Amiodarone works, use immediately s/p VF

PCI s/p VF/pVT arrests

Wait for second shock before epi

Epi: less not more

Summary

Early ETI s/p arrest not optimal

Don’t intubate kids early in CPR

Use 2 High Sensitivity Troponins

Be careful of Heart Score of 3

Optimal HEART pathway: not yet

Summary

Acute AF conversion possible

NSAIDS and Loperamide not benign

Beware “ischemic” ST for PE

Syncope ≠ PE

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VanderbiltEM.com

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