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.

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.

November 23, 2015

Background: We have already discussed the value of a good history in assessing patients with chest pain on REBEL EM. What is known about chest pain is that it is a common complaint presenting to EDs all over the world, but only a small percentage of these patients will be ultimately diagnosed with Acute Coronary Syndrome (ACS). This complaint leads to prolonged ED length of stays, provocative testing, potentially invasive testing, and stress for the patient and the physician. For simplicity sake, we will say that, looking at the ECG can make the diagnosis of STEMI. What becomes more difficult is making a distinction between non-ST-Elevation ACS (NSTEMI/UA) vs non-cardiac chest pain. ED physicians have different levels of tolerance for missing ACS with many surveys showing that a miss rate of <1% is the acceptable miss rate, but some have an even lower threshold, as low as a 0% miss rate. Over testing however, can lead to false positives, which can lead to increased harms for patients. In November 2015, a new systematic review was published reviewing what factors could help accurately estimate the probability of ACS.

October 22, 2015

In case you have not heard or not read it on the twittersphere, the American Heart Association just released their 2015 Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) in Circulation. I am joined by Mr. Security, Matt Astin for this episode and we both read through this massive 15 part document and came up with our top 5 updates and recommendations. Now this is just a list of our top 5 new or updated recommendations, that caught our attention, but certainly there are other recommendations. If you want the cliff notes version of the updates look through part I, titled the executive summary or the Highlights PDF which we will attach on the blog, but certainly as always we recommend reading the full document to form your own interpretations and opinions.

February 6, 2014

Troponin testing is an important component of the diagnostic workup and management of acute coronary syndromes (ACS). The increasing sensitivity of troponin assays has lowered the number of potentially missed ACS diagnoses, but this has also created a diagnostic challenge due to a decrease in the specificity of the test. From 1995 to 2007, the limit of troponin detection fell from 0.5 ng/mL to 0.006 ng/mL (see below graph). Robert Jesse summed up this frustration with the following quote:
When troponin was a lousy assay it was a great test, but now that it's becoming a great assay, it's getting to be a lousy test.