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.

October 30, 2017

Background: Acute coronary syndrome (ACS) is a true spectrum of disease: STEMI, NSTEMI, Unstable Angina (UA), and Stable Angina (SA).  The history and physical plus ECG help us to differentiate patients with STEMI from NSTEMI.  Classically, STEMI represents complete occlusion of a culprit artery and this finding requires immediate coronary angiography and revascularization.  It turns out that there is a subset of NSTEMI patients that also have complete total occlusion (TO) of culprit arteries despite not having true ST elevation on ECG, which unfortunately causes delays in definitive treatment.

August 3, 2015

Background: We know that cardiac arrest is a devastating disease and that it occurs in approximately 400,000 Americans each year. In the few patients who achieve return of spontaneous circulation (ROSC) and survive past the pre-hospital stage, mortality rates range from 50 – 60% depending on which sources you read. Neurologic injury is the primary reason for mortality in cardiac arrest patients who do survive to hospital admission and while therapeutic hypothermia (TH) is now an established and recommended therapy to help improve survival and neurologic outcomes in cardiac arrest survivors, the mortality rate is still high in this population.   Acute coronary syndrome (ACS) accounts for the majority of cases of cardiac arrest in adults and some recent studies have shown that early cardiac catheterization (CC) and immediate percutaneous coronary intervention (PCI) are associated with improved survival following cardiac arrest. However, many of the patients included in these studies had ST-elevation myocardial infarction (STEMI). There is already a Class 1 recommendation for early CC & PCI in the setting of STEMI following cardiac arrest, but the data on early CC in comatose post-arrest patients without STEMI is very limited. Post-resuscitation electrocardiogram (ECG) is often unreliable and lack of ST-elevation has a poor sensitivity for the diagnosis of acute coronary occlusion. Recently the American College of Cardiology/American Heart Association (ACC/AHA) proposed and published a new consensus statement an algorithm to stratify cardiac arrest patients who are comatose for CC activation. As part of this algorithm non-ST elevation myocardial infarction (NSTEMI) was added as an indication for CC activation. So with that introduction today on REBEL Cast we are going to specifically tackle:
  • Topic: Early Cardiac Catheterization in OHCA Survivors with Non-STEMI