February 10, 2021

Take Home Points
  • Consider ruptured AAA in patients (especially those > 50 years of age) with unexplained hypotension, back or abdominal pain
  • All ruptured AAAs should be considered unstable regardless of vital signs as rapid deterioration is common
  • A ruptured AAA is 100% fatal without surgical or endovascular intervention. Mobilize your surgical colleagues early

February 8, 2021

Background: What if we lived in a world where we didn’t call “STEMI alerts”, but instead paged out “OMI alerts”? In the Reperfusion Era of the late 20th century, many large trials showed the benefits of emergent reperfusion therapy, with even greater benefit in the subgroup of patients with undefined ST elevation. As the best idea available, the STEMI-NSTEMI paradigm replaced the Q-wave vs. non-Q-wave MI paradigm in 2000. STEMI-NSTEMI has been a primary determinant of cath lab activations, hospital metrics, and many other patient factors and outcomes. However, the STEMI criteria fail us frequently, missing upwards of 30% of acute coronary occlusion. Additionally, the STEMI/NSTEMI paradigm is dependent on ST segment elevation defined by millimeter criteria, however many occlusion myocardial infarctions (OMI), have no ST segment elevation at all.  To many of us, this idea is not new; we are often taught about STEMI equivalents and “subtle STEMI” that also deserve aggressive management. Over the last 15 years, there has been increased interest in identifying which patients would benefit most from emergent reperfusion therapy. Occlusion myocardial infarction (OMI) vs non-occlusion myocardial infarction (NOMI) is a new paradigm that emerged a few years ago (courtesy of Dr. Stephen Smith, Dr. Pendell Myers, and Dr. Scott Weingart) that might change the way we think about acute myocardial infarction. Their OMI Manifesto is an incredible document (which I highly recommend you read) outlining the historical, clinical, and academic perspectives of why the STEMI-NSTEMI paradigm should be replaced by the OMI-NOMI paradigm. OMI is defined as acute coronary occlusion or near occlusion with insufficient collateral circulation where without emergent catheterization and reperfusion myocardium will undergo necrosis. Patients with OMI are the only ones who benefit from emergent reperfusion therapy, and these patients can present with or without ST elevation on ECG.

January 14, 2021

Background Information: Out-of-hospital cardiac arrest (OHCA) remains a diagnostic challenge to providers and a significant burden on healthcare systems globally. Despite the advancement of invasive medical therapies such as percutaneous coronary intervention (PCI) and extracorporeal membranous oxygenation (ECMO) at designated cardiac catherization centers, the majority of these patients sustain poor outcomes due to hypoxic brain injury. Clinical features of neurologic injury are typically delayed until 72 hours after admission. As a result, many neuro-prognostication tools have been developed to assist with clinical decision making as well as reduce expensive futile interventions.1 Some of these neuroprognostication tools include the Cardiac Arrest Hospital Prognosis (CAHP), OHCA and Targeted Temperature Management (TTM) risk tools. Unfortunately, these are complex and time consuming, thus limiting their use in the emergency department (ED). The authors of the following study sought out to develop and validate a point-based risk score to support clinical decision making and predict neurologic outcomes using the cerebral performance category (CPC) scale (Figure 1)

November 23, 2020

Background: Approximately one in four adults over forty-five years of age will develop atrial fibrillation (AF) during their lifetime. There is a clear association between AF and premature death, ischemic stroke, and cardiovascular events in the first year after atrial fibrillation is diagnosed (“Early atrial fibrillation”). Treatment for AF broadly consists of two categories: rate-control to slow ventricular response rate, and rhythm-control in an attempt to maintain a sinus rhythm. However, there is no systematic evidence that rhythm control treatment improves outcome in atrial fibrillation patients. Observations support that the presence of fibrillation is one of few modifiable factors associated with death in AF patients. Current guidelines for treating AF are largely based on individual factors that are often influenced by impressions of the treating physician. Furthermore, therapy for AF is only indicated in patients with recurrent AF. In summary, the treating physician is left alone in the important therapeutic decision as to whether pursuing sinus rhythm is important in a given patient.

October 19, 2020

Background: Spontaneous coronary artery dissection (SCAD), once thought of as a rare “zebra” diagnosis that was universally fatal, is now being increasingly recognized as a cause of acute coronary syndrome (ACS), particularly in women due to increased vigilance, greater utilization of coronary angiography and advanced imaging. Despite these advances, SCAD still remains one of the most enigmatic syndromes in cardiology. It carries a high misdiagnosis and mistreatment rate with lack of consensus on investigation or treatment. Here we review the salient features of SCAD to increase awareness of this disease entity and further our understanding of this unique disease process.