September 30, 2019

Background: Chest pain is a common chief complaint the Emergency Department, and the differential diagnosis includes life-threatening conditions from several organ systems including cardiac, pulmonary, and gastrointestinal, in addition to more benign etiologies. Historically, despite most patients not having acute coronary syndrome, there is still a high rate of medical admissions in patients with chest pain. The advent of accelerated diagnostic protocols has aided in guiding clinicians with decision making and disposition of these patients. This study aimed to address the question of whether or not an emergency medicine physician’s clinical gestalt would be sufficient to rule in or rule out acute coronary syndrome (ACS). Several studies have addressed this question with conflicting results. Given the high morbidity and mortality of acute coronary syndrome, emergency medicine physicians focus their clinical decision making on decreasing type II errors, i.e., false negatives. In clinical practice, this means having a low rule-out rate based on physician gestalt; in other words, most patients with chest pain presenting to the Emergency Department will have testing including an EKG and troponin level even for patients for whom the physicians have a low clinical suspicion for ACS.

February 22, 2018

Background: Typical medical treatment of ACS patients include dual antiplatelet therapy (DAPT) and revascularization with primary percutaneous coronary intervention (PPCI).  Nitroglycerin is first line therapy in the treatment of pain in ACS with morphine as a common adjunct. Morphine helps relieve pain which decreases catecholamines and oxygen demand.  We have written about the use of Morphine in ACS before on REBEL EM and advocated for fentanyl over morphine for pain control in patients with refractory pain to IV nitroglycerin.  However, two new trials have been published in the past month: An observational trial in 300 patients with STEMI receiving morphine and a randomized trial using fentanyl which requires us to revisit the use of opioids in ACS.

November 5, 2017

Background: Nitroglycerin is a first line agent in the treatment of ACS. The physiologic basis for it’s use rests on it’s ability to promote coronary vasodilation resulting in increased blood flow to the coronary arteries . Nitroglycerin, is typically given as sublingual tablets or sublingual spray of 0.3 – 0.4mg q5min x3 for ischemic chest pain and only after this is IV NTG given for persistent pain.

November 5, 2017

Background: The first report for supplemental oxygen for angina was in 1900, and since then oxygen therapy has been a commonly used treatment of patients with ST-Elevation Myocardial Infarction (STEMI).  The reason for this is the belief that supplemental oxygen will increase oxygen delivery to ischemic myocardium and help reduce myocardial injury.  This belief is based off lab studies and older clinical trials, but there have been other studies that suggest potential adverse physiologic effects of supplemental oxygen in acute coronary syndromes (ACS) (i.e reduced coronary blood flow, increased coronary vascular resistance, and production of reactive oxygen species) causing vasoconstriction and reperfusion injury.

November 5, 2017

Background: Morphine is a commonly used medication in acute coronary syndromes (ACS) to help relieve pain which in turn can help reduce sympathetic tone.  Over the past few years however, there has been some concern raised about the drug-drug interactions with antiplatelet agents causing impaired platelet inhibition as well as an association with worsened clinical outcomes.  P2Y12 receptor antagonists (i.e. Clopidogrel, Pasugrel, Ticagrelor) are typically administered with aspirin (dual anti-platelet therapy) as one of the cornerstones of treatment for ACS.  This drug-to-drug interaction can cause delayed inhibition of platelet activation and potentially worsen clinical outcomes.
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