May 10, 2021

Background: Occlusion myocardial infarction (OMI) is defined as acute coronary occlusion or near occlusion with insufficient collateral circulation leading to downstream myocardial infarction. Currently, we use STEMI ECG criteria to identify acute coronary OMI in the clinical setting. The diagnosis of STEMI is based on millimeter criteria on the ECG (see below) and essentially acts as a surrogate marker for the presence of an OMI. Under the current STEMI vs NSTEMI paradigm, almost 1/3rd of NSTEMI patients have unrecognized acute total occlusion (OMI) discovered on delayed angiograms. The delay in diagnosis results in increased short and long-term mortality compared to NSTEMI patients without OMI (We have reviewed these trials before on REBEL EM). As ECG interpretation has improved it has become clear that there are other early ECG indicators of OMI that do not meet STEMI criteria (i.e. hyperacute T-waves) that would benefit from early percutaneous coronary intervention [2].  Additionally, there are other features such as hemodynamic instability and persistent symptoms, as well as adjunct modalities, like echocardiography, that can add useful information and increase the likelihood of OMI. Ultimately, the OMI paradigm emphasizes underlying pathology over surrogate test results (i.e. STEMI).

April 29, 2021

Background: Non-ST-elevation myocardial infarction (NSTEMI) is defined as acute coronary injury resulting in ischemia and myocardial infarction. The diagnosis is made based on clinical presentation and non-specific electrocardiogram (ECG) changes including ST-segment depression, T-wave inversions, or other nonspecific findings.1 Based on data from the NHS, most patients with NSTEMI are 70 years or older.2 This, coupled with an increasing aging population, raises the question, what is the best management in patients 80 years old or older with NSTEMI?

Previous studies have attempted to evaluate the best approach to elderly patients with NSTEMI, but the mean age of patients was 66 years old with few patients over 80 years old leaving few data to extrapolate these results to this specific population age.3 The best means of obtaining data to answer clinical questions is through prospective randomized trials and there is an upcoming trial to answer this question specifically, the SENIOR-RITA (cool name) will not be expected to complete enrolment prior to 2029. In the meantime, this trial (SENIOR-NSTEMI) was conducted to provide further data regarding the best management of patients older than 80 years old with a NSTEMI.

April 7, 2021

Take Home Points
  • Altered mental status has numerous possible etiologies. Splitting it into vital sign issues, toxic/metabolic, infectious processes, CNS issues (bleed, mass) and psych/dementia is a good way to organize your thoughts
  • Hypertensive encephalopathy is a diagnosis of exclusion - make sure you're not dealing with another process like meningitis or an intracranial hemorrhage
  • Once the diagnosis of hypertensive encephalopathy is made, shoot to lower the SBP by about 20-25% over the hour using a drug like nicardipine, clevidipine or labetalol

March 22, 2021

Background:  Chest pain is one of the most frequent presenting patient complaints in emergency departments (ED) and has an extensive differential diagnosis with very different levels of severity (1). Many of these chest pain presentations require a significant stay in the ED to rule out acute coronary syndromes (ACS). Low-risk chest pain has been defined by consensus guidelines as having a less than 1% risk of a Major Adverse Cardiac Event (MACE) - a composite of death, myocardial infarction (MI) and coronary revascularization (2,3). There is certainly an overuse of troponin ordering in certain low-risk chest pain populations, translating into unnecessary resource utilization and possible downstream patient harm. The HEART Pathway combines a History, ECG, Age, Risk factors (HEAR) score and serial troponins to stratify patients with acute chest pain and attempt to identify those who most likely do not have ACS that are most suitable for early discharge from the ED without further testing (4). The HEART Pathway ideally reduces hospitalisations from the ED and outpatient cardiac testing, but it is not known if there exists a sub-population of very low-risk patients who could be objectively identified for discharge without any troponin testing at all. This study sought to measure the MACE rate among very low-risk chest pain patients, as defined by a HEAR score ≤1, and determine whether the HEART Pathway requires troponin testing among very low-risk patients to achieve an accepted missed MACE event rate of less than 1%.

March 19, 2021

Introduction: Chest pain is a common reason or presentation to the Emergency Department (ED). Emergency physicians are often challenged to identify patients who are at high risk for an acute coronary syndrome (ACS), from those with low risk, who might benefit from early discharge without extensive diagnostic workup. The introduction of high sensitivity cardiac troponins have improved early rule out strategies. Previous studies on high sensitivity troponins (hs-cTnT) have yielded two risk stratification strategies for rule in / rule out of myocardial infarction (MI); using an initial hs-cTnT below the limit of quantification (LOQ) alone and using an algorithm with initial and 1-hour hs-cTNT (0/1-h algorithm), as currently recommended by the European Society of Cardiology. These strategies are often combined with a risk score, of which in the United States (US) the HEART score is the most commonly used. However, due to the relatively late introduction of hs-cTnT in the US, multicenter US data for these risk stratification strategies using hs-cTnT are lacking. The goal of the current study was to prospectively evaluate the diagnostic performance of a hs-cTnT assay (Roche, Basel Switzerland) for the detection of 30-day MACE using two different strategies: an initial hs-cTnT <LOQ alone and a 0/1-h algorithm, both with and without clinical variables (ECG interpretation and HEART score).