Emergency Cardiology Update Recent Articles You’Ve

Emergency Cardiology Update Recent Articles You’ve

GotAmal Mattu, to MD, Know!!FAAEM, FACEP Professor and Vice Chair Director, Emergency Cardiology Fellowship Department of Emergency Medicine University of Maryland School of Medicine Outline

We will discuss recent literature pertaining to… • Cardiac arrest •TNs • Recent ECG studies • One miscellaneous topic Questions? Æ [email protected] PDF of slides Æ lectures.umem.org/SCEC (will be posted for 1 month only) But first…

Email: “I told my (fill in name of consultant) about ___ new practice/drug/finding from the literature and they said they never heard of it and were mad at me for doing ___.” But first…

Translation of Acute Coronary Syndrome Therapies: From Evidence to Routine Clinical Practice (Putera, et al. Am Heart J 2015)

• How long does it take for evidence-based findings to be incorporated into clinical practice? But first…

Translation of ACS Therapies to Practice

• Authors identified 11 Class IA therapies in the ACC/AHA Guidelines • Looked back at cited evidence for when the pivotal clinical trials (PCTs) were pub’d • How long before the recommendations were incorporated into clinical practice with at least (70% or) 90% compliance But first…

Translation of ACS Therapies to Practice

•Results… – “The time of PCT publication to meaningful uptake of class IA ACS therapies into clincal practice took a median of __ years.”

But first…

Translation of ACS Therapies to Practice STEMI PCT to Guideline Guideline Guideline to 70% to 90% Tx’s uptake uptake aspirin 2 yrs 14 yrs tPA 8 yrs UFH 13 yrs 17 yrs

BBs 4 yrs 10 yrs 15 yrs (pre-2005) ACEIs 2 yrs 9 yrs But first…

• Takehome points: – Don’t get frustrated! – Share the literature with your colleagues upstairs, downstairs, and down the hall! Prehospital BLS vs. ALS for Cardiac Arrest

Outcomes After Out-of-Hospital Cardiac Arrest Treated by Basic vs. Advanced Life Support (Sanghavi, et al. JAMA Intern Med, Feb 2015) Prehospital BLS vs. ALS for Cardiac Arrest

Prehospital BLS vs. ALS for OOHCA

• Largest study in the U.S. thus far comparing BLS vs. ALS outcomes • Observational cohort study of a national sample of Medicare beneficiaries experiencing OOHCA from Jan 2009 – Oct 2011 – 31,292 ALS cases vs. 1643 BLS cases Prehospital BLS vs. ALS for Cardiac Arrest

Prehospital BLS vs. ALS for OOHCA

• Evaluated survival to hospital discharge, 30-day survival, 90-day survival, neurological performance, and medical spending per survivor to 1 year • BLS = CPR, defibrillation, transport • ALS = BLS + ETI + drugs Prehospital BLS vs. ALS for Cardiac Arrest

Prehospital BLS vs. ALS for OOHCA

• “After applying the propensity score- derived balancing weights to the ALS observations, there were no meaningful differences on any observed measure between the BLS and ALS groups.” Prehospital BLS vs. ALS for Cardiac Arrest

Prehospital BLS vs. ALS for OOHCA

• Results... – Patients receiving ALS had significantly worse • Survival to hospital d/c (9.2% vs. 13.1%) • Survival to 90 days (5.4% vs. 8.0%) • Neurological function (44.8% with poor neuro function vs. 21.8%) Prehospital BLS vs. ALS for Cardiac Arrest

Prehospital BLS vs. ALS for OOHCA

• Results... – Patients receiving BLS had higher total medical expenditures at 1 year (because they lived longer), but… – Patients receiving ALS who survived 1 year required higher medical expenses than BLS survivors at 1 year ($207K vs. $154K) Prehospital BLS vs. ALS for Cardiac Arrest

Prehospital BLS vs. ALS for OOHCA

• Discussion: ALS leads to worse outcomes for several reasons 1. Prehospital ETI entails risks, interferes with chest compressions, compromises circulation 2. Evidence for drugs is poor 3. ALS causes delays in transport to hospital Prehospital BLS vs. ALS for Cardiac Arrest

Prehospital BLS vs. ALS for OOHCA

• Discussion – “…our results suggest that the use of ALS is associated with higher mortality than the use of BLS in patients with cardiac arrest.” Prehospital BLS vs. ALS for Cardiac Arrest

Accompanying editorial by Michael Callaham, MD

• How did we get in this mess in the first place? Prehospital BLS vs. ALS for Cardiac Arrest

Accompanying editorial by Michael Callaham, MD

• 1960s… Prehospital BLS vs. ALS for Cardiac Arrest

Accompanying editorial by Michael Callaham, MD

• Recent large studies have demonstrated lack of benefit of ETI early in CA – Hasegawa, et al. JAMA 2013 – Lecky, et al. Cochrane Database 2008 Prehospital BLS vs. ALS for Cardiac Arrest

Accompanying editorial by Michael Callaham, MD

• Recent large studies have demonstrated lack of benefit of ALS meds early in CA – Olasveengen, et al. JAMA 2009 – Stiell, et al. NEJM 2004 Prehospital BLS vs. ALS for Cardiac Arrest

Accompanying editorial by Michael Callaham, MD

• Increasing data is showing that ALS is not only ineffective, but it is harmful Prehospital BLS vs. ALS for Cardiac Arrest

EPI in cardiac arrest associated with worse outcomes

• Hagihara, et al. JAMA 2012 • Dumas, et al. JACC 2014 Prehospital BLS vs. ALS for Cardiac Arrest

Accompanying editorial by Michael Callaham, MD

• Takehome points: – “Most ALS interventions are ‘advanced’ chiefly in our expections, not in evidence- based efficacy.” – Focus on the BLS! Cardiac Biomarkers

Comparison of Conventional and High- Sensitivity Troponin in Patients with Chest Pain: A Collaborative Meta- Analysis (Lipinski, et al. Am Heart J, Jan 2015) Cardiac Biomarkers

Comparison of c-TN vs hs-TN in Patients with Chest Pain

• Evaluated 17 studies, 8644 patients, comparing sensitivity and specificity of dx of acute MI between c-TN vs. hs-TN • Baseline and 2nd serial level (no STEMIs) – How was AMI diagnosed in all of these studies? – How long before 2nd level drawn? Cardiac Biomarkers

Comparison of c-TN vs hs-TN in Patients with Chest Pain

• Results for pooled numbers – Sensitivity for 1st value: 74.9% vs. 88.4% – Sensitivity for 2nd value: 89.5% vs. 92.8% – Specificity for 1st value: 93.8% vs. 81.6% – Specificity for 2nd value: 95.2% vs. 80.7% Cardiac Biomarkers

Comparison of c-TN vs hs-TN in Patients with Chest Pain

• Follow-up Æ avg. 12.3 months – Patients with elevated c-TN and hs-TN had higher risk of non-fatal MI and also death – Patients with normal c-TN but elevated hs- TN had slightly higher risk of non-fatal MI and death compared to patients with both normal values Cardiac Biomarkers

Comparison of c-TN vs hs-TN in Patients with Chest Pain

• Takehome point: hs-TN has increased sensitivity, lower specificity – Predicts long-term adverse outcomes a bit better – “…may lead to more extensive cardiovascular testing.” Cardiac Biomarkers

Comparison of c-TN vs hs-TN in Patients with Chest Pain

• “…it is critical to interpret these biomarkers in the clinical context of the patient. The importance of clinical history and appropriate ECG evaluation cannot be underestimated.” Cardiac Biomarkers

Comparison of c-TN vs hs-TN in Patients with Chest Pain

• “…the diagnostic value of a neg TN is less helpful if the patient’s presentation is c/w unstable angina because the clinical presentation will guide management rather than the biomarker result.” Troponin

Newby, et al. JACC 2012 Cardiac Biomarkers

• Elevated TNs in many of these non-MI conditions provide prognostic information…but no therapeutic change

–Sepsis – Stroke –PE – Renal failure –Etc. Cardiac Biomarkers

• Jesse RL. On the Relative Value of an Assay Versus That of a Test (JACC 2010) – “When TN 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.” Cardiac Biomarkers

Use of Cardiac Biomarker Testing in the Emergency Department (Makam AN, et al. JAMA Intern Med, Jan 2015) Cardiac Biomarkers