Ibutilide is a rapid-acting antiarrhythmic drug with worldwide use for conversion of recent-onset atrial fibrillation. Vernakalant, approved in the EU in 2010, is likewise used intravenously, with ...proven efficacy and safety compared with placebo and amiodarone in randomized clinical trials. The aim of our study was to compare the time to conversion and the conversion rate within 90 min in patients with recent-onset atrial fibrillation treated with vernakalant or ibutilide.
A randomized controlled trial registered at clinicaltrials.gov (NCT01447862) was performed in 100 patients with recent-onset atrial fibrillation treated at the emergency department of a tertiary care hospital. Patients received up to two short infusions of vernakalant (n = 49; 3 mg/kg followed by 2 mg/kg if necessary) or ibutilide (n = 51; 1 mg followed by another 1 mg if necessary) according to the manufacturer's instructions. Clinical and laboratory variables, adverse events, conversion rates, and time to conversion were recorded. Time to conversion of AF to sinus rhythm was significantly shorter in the vernakalant group compared with the ibutilide group (median time: 10 vs. 26 min, P = 0.01), and likewise the conversion success within 90 min was significantly higher in the vernakalant group (69 vs. 43%, log-rank P = 0.002). No serious adverse events occurred.
Vernakalant was superior to ibutilide in converting recent-onset atrial fibrillation to sinus rhythm in the emergency department setting.
The purpose of this study was to determine whether implementation of recent guidelines improves in-hospital mortality from acute ST-elevation myocardial infarction (STEMI) in a metropolitan area.
We ...organized a network that consisted of the Viennese Ambulance Systems, which is responsible for diagnosis and triage of patients with acute STEMI, and 5 high-volume interventional cardiology departments to expand the performance of primary percutaneous catheter intervention (PPCI) and to use the fastest available reperfusion strategy in STEMI of short duration (2 to 3 hours from onset of symptoms), either PPCI or thrombolytic therapy (TT; prehospital or in-hospital), respectively. Implementation of guidelines resulted in increased numbers of patients receiving 1 of the 2 reperfusion strategies (from 66% to 86.6%). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 34% to 13.4%, respectively. PPCI usage increased from 16% to almost 60%, whereas the use of TT decreased from 50.5% to 26.7% in the participating centers. As a consequence, in-hospital mortality decreased from 16% before establishment of the network to 9.5%, including patients not receiving reperfusion therapy. Whereas PPCI and TT demonstrated comparable in-hospital mortality rates when initiated within 2 to 3 hours from onset of symptoms, PPCI was more effective in acute STEMI of >3 but <12 hours' duration.
Implementation of recent guidelines for the treatment of acute STEMI by the organization of a cooperating network within a large metropolitan area was associated with a significant improvement in clinical outcomes.
Summary Aim of the study There is sufficient evidence that therapeutic hypothermia after non-traumatic cardiac arrest improves neurological outcome and reduces mortality. Many different invasive and ...non-invasive cooling devices are currently available. Our purpose was to show the efficacy, safety and feasibility using a non-invasive cooling device to control patient temperature within a range of 33–37 °C. Materials and methods A convenience sample of patients who have been resuscitated successfully from cardiac arrest and were intended for mild hypothermia therapy according to the guidelines and inclusion criteria were studied in a prospective observational case series at an emergency department of a tertiary care university hospital. The Medivance Arctic Sun System provides a new, non-invasive approach to reach a target temperature of 33 °C quickly, to maintain the target temperature for 24 h, and then to actively re-warm at 0.4 °C/h to normothermia. Cooling was applied using the Arctic Sun in 27 patients. Data are presented as median and the interquartile range (25, 75%). Results Median age was 58 (49.5, 70) years. Time from cooling start to target temperature was 137 (96, 168) min, cooling rate was 1.2 °C/h (0.8, 1.5), stability of target temperature during hypothermia maintenance phase was satisfactory at 33.0 °C (32.9, 33.1), and duration of re-warming was 428 (394, 452) min. Conclusion Using the Arctic Sun System in post-resuscitation care medicine for cooling cardiac arrest survivors is feasible and has proven to be highly effective in lowering patients’ temperature rapidly without inducing skin irritations.
Study objective Accurate and timely diagnosis of carbon monoxide (CO) poisoning is difficult because of nonspecific symptoms. Multiwave pulse oximetry might facilitate the screening for occult ...poisoning by noninvasive measurement of carboxyhemoglobin (COHb), but its reliability is still unknown. We assess bias and precision of COHb oximetry compared with the criterion standard blood gas analysis. Methods This was a prospective diagnostic accuracy study according to STARD (Standards for the Reporting of Diagnostic accuracy studies) criteria, performed at a tertiary care hospital emergency department. We included all patients for whom both invasive and noninvasive measurement within 60 minutes was available, regardless of their complaints, during a 1-year period. Results One thousand five hundred seventy-eight subjects were studied, of whom 17 (1.1%) received a diagnosis of CO poisoning. In accordance with this limited patient cohort, we found a bias of 2.99% COHb (1.50% for smokers, 4.33% for nonsmokers) and a precision of 3.27% COHb (2.90% for smokers, 2.98% for nonsmokers), limits of agreement from −3.55% to 9.53% COHb (−4.30% to 7.30% for smokers, −1.63% to 10.29% for nonsmokers). Upper limit of normal cutoff of 6.6% COHb had the highest sensitivity in screening for CO poisoning. Smoking status and COHb level had the most influence on the deviation between measurements. Conclusion Multiwave pulse oximetry was found to measure COHb with an acceptable bias and precision. These results suggest it can be used to screen large numbers of patients for occult CO poisoning.
Aims
To evaluate the performance of the ABC (Age, Biomarkers, Clinical history) and CHA
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DS
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-VASc stroke scores under real-world conditions in an emergency setting.
Methods and Results
The ...performance of the biomarker-based ABC-stroke score and the clinical variable-based CHA
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DS
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-VASc score for stroke risk assessment were prospectively evaluated in a consecutive series of 2,108 patients with acute symptomatic atrial fibrillation at a tertiary care emergency department. Performance was assessed according to methods for the development and validation of clinical prediction models by Steyerberg et al. and the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis. During a cumulative observation period of 3,686 person-years, the stroke incidence rate was 1.66 per 100 person-years. Overall, the ABC-stroke and CHA
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-VASc scores revealed respective c-indices of 0.64 and 0.55 for stroke prediction. Risk-class hazard ratios comparing moderate to low and high to low were 3.51 and 2.56 for the ABC-stroke score and 1.10 and 1.62 for the CHA
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DS
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-VASc score. The ABC-stroke score also provided improved risk stratification in patients with moderate stroke risk according to the CHA
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-VASc score, who lack clear recommendations regarding anticoagulation therapy (HR: 4.35,
P
= 0.001). Decision curve analysis indicated a superior net clinical benefit of using the ABC-stroke score.
Conclusion
In a large, real-world cohort of patients with acute atrial fibrillation in the emergency department, the ABC-stroke score was superior to the guideline-recommended CHA
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-VASc score at predicting stroke risk and refined risk stratification of patients labeled moderate risk by the CHA
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-VASc score, potentially easing treatment decision-making.
Objective
Early diagnosis or rule‐out of acute coronary syndrome (ACS) is a key competence of emergency medicine. Changes in the NSTE‐ACS guidelines of the European Society of Cardiology (ESC) in ...2015 and 2020 both warranted a henceforth more conservative approach regarding high‐sensitivity troponin t (hsTnt) testing.
We aimed to assess the impact of more conservative guidelines on the frequency of early rule‐out and prolonged observation with repeated hsTnt testing at a high‐volume tertiary care emergency department.
Patients and Methods
We conducted a pre‐ and post‐changeover analysis 3 months before and 3 months after transition from less (hsTnt cut‐off 30 ng/L, 3‐hour rule‐out) to more conservative (hsTnt cut‐off 14 ng/L, 1‐hour rule‐out) guidelines in 2015, comparing proportions of patients requiring repeated testing.
Results
We included 5442 cases of symptoms suspicious of acute cardiac origin (3451 before, 1991 after, 2370 (44%) female, age 55 (SD 19) years). The proportion of patients fulfilling early‐rule out criteria decreased from 68% (2348 patients) before to 60% (1195 patients) with the 2015 guidelines (P < .01). Those requiring repeated testing significantly (P < .01) increased from 22% (743 patients) to 25% (494 patients). Positive results in repeated testing significantly (P = .02) decreased from 43% (320 patients) to 37% (181 patients). Invasive diagnostics were performed in 91 patients (2.6%) before and in 75 patients (3.8%) after (P = .02) the guideline revision.
Conclusion
The implementation of the more conservative 2015 ESC guidelines led to a minor rise in prolonged observations because of an increase in negative repeated testing and to an increase in invasive procedures.
Overcrowding decreases quality of care. Triage and patient administration are possible bottlenecks. We aimed to identify factors influencing door-to-triage- and triage-to-patient administration-time ...in a prospective observational study at a tertiary care center with 70,000 patients per year.
Measurement of aforementioned times at convenience-sampled time intervals on 16 days. Linear regression modelling with times as dependent variable, and demographic, medical and structural factors as covariables, testing for interactions with risk factor “weekend”.
We included 360 patients (183 female (51%)). Median door-to-triage-time was 6 (IQR 3–11) minutes, triage-to-patient administration-time was 5 (IQR 3–8) minutes. Overall door-to-triage-time was significantly shorter during weekends compared to weekdays (absolute difference 3 (IQR 1–7) minutes; 5 (IQR 3–8) vs. 8 (IQR 4–15) minutes, p < 0.01). Other influencing factors were closing hours of non-emergency department healthcare facilities (3.5 min more), number of ESI 2 patients seen during the interval (3 min more for each patient per hour), and ambulance activity (2 min more for each patient per hour brought by ambulance).
Day of time and week as well as frequency of patients with urgent conditions and those brought by ambulance significantly increased door-to-triage times. This should be kept in mind when organizing ED workflow.
Platelet activation is a hallmark of acute coronary syndromes. Numerous lines of evidence suggest a mechanistic link between von Willebrand factor or platelet hyperfunction and myocardial damage in ...patients with acute coronary syndromes. Thus, we assessed whether platelet function under high shear rates (collagen adenosine diphosphate closure times CADP-CTs) measured with the platelet function analyzer (PFA-100) may be enhanced in patients with myocardial infarction (MI) and whether it may predict the extent of myocardial damage as measured by creatine kinase (CK-MB) or troponin T (TnT) levels.
Patients with acute chest pain or symptoms suggestive of acute coronary syndromes (n=216) were prospectively examined at an emergency department. CADP-CT was significantly shorter in patients with MI, particularly in those with an ST-segment-elevation MI (STEMI) compared with the other patient groups (unstable angina, stable coronary artery disease, or controls). Furthermore, CADP-CT and collagen epinephrine-CT at presentation were independent predictors of myocardial damage as measured by CK-MB or TnT. Patients with MI whose CADP-CT values fell in the first quartile had 3-fold higher CK-MB and TnT levels than those in the fourth quartile.
Patients with STEMI have significantly enhanced platelet function when measured under high shear rates. CADP-CT is an independent predictor of the severity of MI, as measured by markers of cardiac necrosis. Measurement of platelet function with the PFA-100 may help in the risk stratification of patients presenting with MI.
Recently 2 randomized trials in comatose survivors of cardiac arrest documented that therapeutic hypothermia improved neurological recovery. The narrow inclusion criteria resulted in an international ...recommendation to cool only a restricted group of primary cardiac arrest survivors. In this retrospective cohort study we investigated the efficacy and safety of endovascular cooling in unselected survivors of cardiac arrest.
Consecutive comatose survivors of cardiac arrest, who were either cooled for 24 hours to 33 degrees C with endovascular cooling or treated with standard postresuscitation therapy, were analyzed. Complication data were obtained by retrospective chart review.
Patients in the endovascular cooling group had 2-fold increased odds of survival (67/97 patients versus 466/941 patients; odds ratio 2.28, 95% CI, 1.45 to 3.57; P<0.001). After adjustment for baseline imbalances the odds ratio was 1.96 (95% CI, 1.19 to 3.23; P=0.008). When discounting the observational data in a Bayesian analysis by using a sceptical prior the posterior odds ratio was 1.61 (95% credible interval, 1.06 to 2.44). In the endovascular cooling group, 51/97 patients (53%) survived with favorable neurology as compared with 320/941 (34%) in the control group (odds ratio 2.15, 95% CI, 1.38 to 3.35; P=0.0003; adjusted odds ratio 2.56, 1.57 to 4.17). There was no difference in the rate of complications except for bradycardia.
Endovascular cooling improved survival and short-term neurological recovery compared with standard treatment in comatose adult survivors of cardiac arrest. Temperature control was effective and safe with this device.
We investigated the relationship between lactate clearance and outcome in patients surviving the first 48 hours after cardiac arrest. We conducted the study in the emergency department of an urban ...tertiary care hospital. We analyzed the data for all 48-hour survivors after successful resuscitation from cardiac arrest during a 10-year period. Serial lactate measurements, demographic data, and key cardiac arrest data were correlated to survival and best neurologic outcome within 6 months after cardiac arrest. Parameters showing significant results in univariate analysis were tested for significance in a logistic regression model. Of 1502 screened patients, 394 were analyzed. Survivors (n = 194, 49%) had lower lactate levels on admission (median, 7.8 interquartile range, 5.4-10.8 vs 9 6.6-11.9 mmol/L), after 24 hours (1.4 1-2.5 vs 1.7 1.1-3 mmol/L), and after 48 hours (1.2 0.9-1.6 vs 1.5 1.1-2.3 mmol/L). Patients with favorable neurologic outcome (n = 186, 47%) showed lower levels on admission (7.6 5.4-10.3 vs 9.2 6.7-12.1 mmol/L) and after 48 hours (1.2 0.9-1.6 vs 1.5 1-2.2 mmol/L). In multivariate analysis, lactate levels at 48 hours were an independent predictor for mortality (odds ratio OR: 1.49 increase per mmol/L, 95% confidence interval CI: 1.17-1.89) and unfavorable neurologic outcome (OR: 1.28 increase per mmol/L, 95% CI: 1.08-1.51). Lactate levels higher than 2 mmol/L after 48 hours predicted mortality with a specificity of 86% and poor neurologic outcome with a specificity of 87%. Sensitivity for both end points was 31%. Lactate at 48 hours after cardiac arrest is an independent predictor of mortality and unfavorable neurologic outcome. Persisting hyperlactatemia over 48 hours predicts a poor prognosis.
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