October 21, 2019

Background Information: Atrial fibrillation is the most commonly encountered dysrhythmia in the emergency department (ED) and is associated with an increased long-term risk of stroke, heart-failure and all-cause mortality.1,2 In fact, the overall mortality rate for patients with atrial fibrillation is approximately double that of patients in normal sinus.3,4 The decision to rate vs. rhythm control patients while in the emergency department remains controversial in the literature and the method of doing so using chemical vs. electrical cardioversion also stirs up debate. Prior studies have shown the success rate of electrical cardioversion alone to be 90%.1,5 other studies have demonstrated that emergency physicians use each strategy roughly half the time.1 The authors of this study sought to determine if one of the two strategies resulted in achievement of normal sinus rhythm and discharge more quickly.

March 14, 2019

Background: Chest pain is a complaint commonly seen in the emergency department.  Getting a good history is an essential part of working up patients with chest pain, as the history may guide us to be concerned for the cause of life-threatening chest pain including, pulmonary embolism, aortic dissection, tension pneumothorax, or acute coronary syndrome. In regard to acute coronary syndrome, many of us learned that the classic description of ischemic chest pain was chest pressure radiating to the left arm.  But as sometimes is the case, classic teachings are based on antiquated evidence and simply not correct.

February 14, 2019

Background: The 2014 AHA guidelines for the management of NSTEMI, recommend unfractionated heparin with an initial loading dose of 60IU/KG (maximum 4,000 IU) with an initial infusion of 12 IU/kg/hr (maximum 1,000 IU/hr) adjusted per active partial thromboplastin time to maintain therapeutic anticoagulation according to the specific hospital protocol, continued for 48 hours or until PCI is performed (Level of Evidence B) [2]. With even a higher level of evidence the 2014 AHA guidelines for the management of NSTEMI, also recommend enoxaparin 1mg/kg subcutaneously every 12 hours with reduced dosing to 1mg/kg subcutaneously in patients with a creatinine clearance <30mL/min) (Level of Evidence A) [2].  The studies supporting this therapy were performed primarily on patients with a diagnosis of unstable angina and in the era before dual anti platelet therapy and early catheterization/revascularization. Therefore, the authors of this paper looked to evaluate the clinical outcomes associated with parenteral anticoagulation therapy (Heparin) in the era of dual anti-platelet therapy in patients with NSTEMI.

January 7, 2019

Background: Syncope, defined as a transient loss of consciousness with spontaneous and complete recovery to pre-event status, is a common emergency department (ED) presentation. Near-syncope is frequently seen as well. Unlike syncope, near-syncope has a more nebulous definition often thought of as the feeling of oncoming syncope without a complete loss of consciousness. Regardless of definition, many providers consider syncope and near-syncope as two ends of a spectrum of disease with near-syncope being not as dangerous and syncope being more dangerous. The literature on this, however, is inconsistent with a 2009 study stating that near-syncope was a “low-risk" factor (Sun 2009) and a 2015 study showing the opposite (Thiruganasambandamoorthy 2015). Additional high-quality data in this area is needed to further elucidate the risk of near-syncope presentations in the ED.

October 29, 2018

Background:In the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial [2], there was no difference in MI and death rates between patients with stable coronary artery disease who underwent PCI and controls. In stable angina, the primary goal of percutaneous coronary intervention (PCI) is symptomatic relief of angina, with guidelines recommending its use for those who remain symptomatic despite optimal medical management.  The issue with previous studies is both physicians and patients have not been blinded, therefore the effect size of PCI on symptomatic endpoints can be overestimated due to placebo effect as opposed to true physiological effect.  The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina (ORBITA) trial was designed to assess the effect of PCI versus placebo on exercise time in patients with stable ischemic symptoms in a blinded fashion.
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