July 26, 2021

Background: The mainstays for management of stroke include admission to a stroke center and management of modifiable risk factors.1,2,3 It is estimated that most strokes are ischemic (87%),4 and atrial fibrillation and/or flutter are thought to be responsible for approximately one third of all ischemic strokes.5 Patients with atrial fibrillation at highest risk for stroke are those with an elevated CHA2DS2-VASc (congestive heart failure, hypertension, age 75 years, diabetes, previous stroke or transient ischemic attach [TIA], vascular disease, age 65 to 74 years, sex category) score.6 Due to this increased risk of stroke in this population, it is important to identify atrial fibrillation so that they can be managed with guideline recommended oral anticoagulation to prevent recurrent strokes, although clinically, it is unclear what the minimum burden of atrial fibrillation is that requires anticoagulation.7 In patients who have had a stroke without identification of atrial fibrillation on Holter or electrocardiographic monitoring, it is recommended that they undergo additional electrocardiographic monitoring for 2-4 weeks.8This is based on data suggesting that continuous monitoring may identify up to a quarter of patients who have had a prior stroke with atrial fibrillation.9 The available monitoring methods include external Holter and implantable loop recorder monitoring. There has not been a head-to-head comparison in detection rates of atrial fibrillation between these two methods, until now… Enter the STROKE-AF and PER DIEM trials.

July 22, 2021

Background Information:

Hypothermia was first introduced in 2002 by two studies, Bernard et al and The Hypothermia After Cardiac Arrest (HACA) trial.1,2 The latter, although a small trial, showed improved neurologic outcomes at six months when patients were cooled to 32-34oC. For a long time, a temperature of 33oC was the widely accepted standard of therapy for out-of-hospital cardiac arrest.1 In recent years, a trial aptly named the Targeted Temperature Management (TTM) Trial challenged this notion,3 finding that a temperature of 33oC did not confer any benefit over 36oC.4 Since then, not only has the overall benefit of the therapy remained in question, but many institutions were also left on their own to decide the most appropriate temperature to target. Fever has been proposed as a risk factor for unfavorable outcomes, but the available data only gives us association, not causation. The authors of the TTM trial have now come out with their subsequent study looking to assess the benefit of avoiding fever versus targeting a specific temperature in critically ill patients following cardiac arrest.

July 19, 2021

In the United States, a patient with chest pain presents to the emergency department (ED) every 5 seconds. By the time you finish reading this post, 60 patients will have sought treatment for chest pain. In 2017, chest pain was the second most common chief complaint in US EDs totaling more than 6.5 million visits,[1] or approximately 2.5x the population of Chicago. There have been dramatic advances in the management of ACS and low-risk chest pain. Prior to the days of observation units, I recall admitting high-risk patients with chest pain to a telemetry floor. However, admissions have changed to observation stays, 6-hour 𝚫 troponins changed to 2-hour 𝚫 troponins, conventional troponins changed to high sensitivity troponins, and much more. Remarkably, up to 40% of patients with chest pain will return to the ED with similar concerns within one year.[2] Yet, there is sparse evidence to address the subset of low-risk patients with recurrent chest pain.

July 15, 2021

Background: Transfusion thresholds for anemia have large variations in clinical practice.  This is especially true in patients with acute myocardial infarction (AMI).  Part of the reason for this is the lack of high-quality data.  There was a large, randomized trial looking at restrictive vs liberal transfusion strategies in non-crashing GI bleeding [2] which found a restrictive transfusion strategy was superior, however patients with AMI were excluded.

July 14, 2021

Take Home Points

1. Debriefing is critical. Studies show numerous benefits in terms of team communication and staff ability to regroup.
2. Start by gathering your team, thanking them for their work and noting that nothing could have changed the patient's ultimate outcome.
3. Summarize the events so everyone is on the same page and then prompt people to offer thoughts by asking "what went well? what could have gone better?"
4. Remember to end on a positive note to get everyone refocused and energized.