October 8, 2020

Background: Prior to the discovery of thrombolytics, clinicians could only observe their patients completing their myocardial infarctions and then classify them according to whether their subsequent ECGs developed Q waves. When trials showed a clear survival benefit with thrombolytics (especially in STE) this shifted the paradigm from “Q-wave/ non Q-wave MI” to “STEMI / non-STEMI”. Eventually STEMI became synonymous with acute coronary occlusion (ACO) requiring reperfusion, except this connection was never studied in trials. Unfortunately, the STEMI criteria have limited diagnostic criteria for ACO, leading to false cath lab activation. And worse, missing ⅓ of ACO (NSTEMI), depriving them of emergent reperfusion therapy. This led many authors to shift from STEMI/ NSTEMI to ACO-MI/ non- ACO-MI. 

September 30, 2020

Take Home Points
  • 100k people in US have sickle cell, the majority will at some point develop acute chest syndrome (ACS)
  • The mortality rate per episode is 3-9%, similar to those of STEMI
  • ACS is a syndrome - CXR infiltrate + respiratory symptoms
  • Treat it aggressively and early (antibiotics, respiratory support)
  • If you’re considering exchange transfusion - get hematology onboard quickly

July 9, 2020

Background: Acute atrial fibrillation (AF) is one of the most common dysrhythmias seen in the emergency department (ED). There has been extensive discussion and debate about the best way to manage acute AF centered around rate and rhythm control.  However, there is little data to guide the optimal approach to rhythm control once this option is selected. As a result of the absence of good evidence, there is significant variation in management. Better data is integral to establishing best practices. The RAFF2 randomized trial attempted to provide more data on this debate of electrical vs pharmacological cardioversion in patients with acute atrial fibrillation/flutter.

July 2, 2020

Background: In patients presenting to the ED with acute coronary syndrome (ACS), dual antiplatelet therapy is the current standard treatment.  This typically consists of aspirin and an adenosine diphosphate receptor antagonist.  It is fairly well understood that prasugrel and ticagrelor provide greater, and more rapid platelet inhibition than clopidogrel (i.e. Plavix) [5][6]. Both ticagrelor and prasurgel have a class I recommendation for use in ACS with or without ST-segment elevation. The loading strategies of these two medications are different: ticagrelor is administered as a pre-treatment medication prior to diagnostic angiography while prasugrel is given after coronary anatomy has been assessed by angiography (No advantage has been observed when prasugrel is used as pretreatment) [7].  The authors of this trial (ISAR-REACT 5) looked to compare ticagrelor vs prasugrel in patients with ACS to evaluate efficacy and safety.

May 6, 2020

There continues to be a slew of publications coming out on a near daily basis in regard to COVID-19.  Some publications will deserve their own posts and others can really be summarized in one or two paragraphs.  In this post I will summarize 5 papers published in the past week, that I found interesting and each has a unique, but important message.  None of these papers are very long, but there are some important aspects of each I felt tied into each other from a cardiovascular standpoint.