UMEM Educational Pearls - By Ali Farzad

Category: Cardiology

Title: Brain-heart crosstalk

Keywords: Brain-heart syndrome, Neurogenic Stress Cardiomyopathy (PubMed Search)

Posted: 4/27/2014 by Ali Farzad, MD
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“Brain-heart crosstalk” is being increasingly recognized in the acute phase after severe brain injury. Neurogenic stunned myocardium, also called ‘neurogenic stress cardiomyopathy’ (NSC), is a syndrome that can occur after severe acute neurologic injury (i.e. SAH, TBI, ischemic or hemorrhagic stroke, CNS infections, epilepsy, or any sudden stressful neurologic event). 
 
NSC is part of the stress-related cardiomyopathy syndrome spectrum, which includes Takotsubo syndrome. However, NSC refers specifically to myocardial dysfunction related to stress from catacholamine excess triggered by neurological injury, rather than emotional or physical stress. Neurocardiogenic injury from NSC is associated with an increased risk of all-cause mortality, cardiac mortality and heart failure.
 
Cardiac involvement can be appreciated with ECG changes and echocardiography. ECG changes include QT interval prolongation (large T waves & U waves), long QT syndrome & torsade de points, ST-segment depression, T-wave inversion, and ventricular & supraventricular arrhythmias. Importantly, NSC can also mimic acute myocardial infarction with LV wall motion abnormalities, and elevated cardiac biomarkers/BNP
 
Emergency physicians should be aware of the diagnostic challenges posed by NSC, and maintain a high index of suspicion when admitting a patient with an unclear clinical picture. NSC management is mainly supportive and symptomatic, based on treatment of life threatening events (i.e. malignant arrhythmias or cardiogenic shock). See references to learn more about the pathophysiology and treatment options.
 

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Category: Cardiology

Title: Airway management in out of hospital cardiac arrest

Keywords: Out of hospital cardiac arrest, OHCA, Prehospital airway management (PubMed Search)

Posted: 4/13/2014 by Ali Farzad, MD
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Optimal out of hospital cardiac arrest (OHCA) airway management strategies remain unclear. In the US, 80% of OHCA patients receive prehospital airway management, most commonly endotracheal intubation (ETI). There is growing enthusiasm for use of supra-glottic airways (SGA) by EMS because of ease of insertion, and the thought that use of SGA reduces interruptions in chest compressions. More recently, studies have suggested improved survival without the insertion of any advanced airway device at all. 

A recent secondary analysis of OHCA outcomes in the Cardiac Arrest Registry to Enhance Survival (CARES) compared patients receiving endotracheal intubation (ETI) versus supra-glottic airway (SGA), and also patients receiving [ETI or SGA] with those receiving no advanced airway. 

Of 10,691 OHCA, 5591 received ETI, 3110 SGA, and 1929 had no advanced airway. Unadjusted neurologically-intact survival was: ETI 5.4%, SGA 5.2%, no advanced airway 18.6%. Compared with SGA, ETI achieved higher sustained ROSC, survival to hospital admission, hospital survival, and hospital discharge with good neurologic outcome. Moreover, compared with [ETI or SGA], patients who received no advanced airway attained higher survival to hospital admission, hospital survival, and hospital discharge with good neurologic outcome. 

Conclusion: In CARES, patients receiving no advanced airway exhibited superior outcomes than those receiving ETI or SGA. When an advanced airway was used, ETI was associated with improved outcomes compared to SGA.

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Category: Cardiology

Title: Are chest compressions safe in arresting LVAD patients?

Keywords: Cardiac arrest, LVAD, CPR, Chest compressions (PubMed Search)

Posted: 3/23/2014 by Ali Farzad, MD
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The number of patients with left ventricular assist devices (LVADs) is increasing and development of optimal resuscitative strategies is becoming increasingly important. Despite a lack of evidence, many device manufacturers and hospitals have recommended against performing chest compressions because of fear of cannula dislodgment or damage to the outflow conduit.

A recent retrospective analysis of outcomes in LVAD patients who received chest compressions for cardiac arrest did not support the theory that LVADs would be harmed by conventional resuscitation algorithms.

The study was a limited case series of only 8 LVAD patients over a 4 year period. All patients received compressions and device integrity was subsequently assessed by blood flow data from the LVAD control monitor or by examination on autopsy. Although more research is necessary to determine the utility and effectiveness of compressions in this population, none of the patients in this study had cannula dislodgment and half of the patients had return of neurologic function.

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Category: Cardiology

Title: Suprasternal Notch View...a window to the Aortic Arch?

Keywords: Echo, Aortic Dissection (PubMed Search)

Posted: 3/9/2014 by Ali Farzad, MD (Updated: 3/23/2014)
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Early diagnosis and surgical consultation for dissection of the ascending aorta can be life saving. Emergency physicians are increasingly using focused cardiac ultrasound to assess chest pain patients in the ED. 

The suprasternal notch view (SSNV), may provide additional information in the assessment of thoracic aortic pathology. A recently performed pilot study aimed to determine the accuracy of using the SSNV, in addition to the more traditional parasternal long axis view in assessing aortic dimensions as well as pathology compared to CTA of the chest. 

Using a maximal normal thoracic aortic diameter of 40 mm, diagnostic accuracy in detecting dilation of the aorta was 100%. The study showed that the SSNV is feasible and demonstrates high agreement with measurements made on CTA of the chest. 

The SSNV can be a useful bedside window to help diagnose thoracic aortic pathology such as aortic dissection and coarctation of the aorta. 
 

 

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Category: Cardiology

Title: Recent Negative Stress Tests in Chest Pain Bouncebacks

Keywords: ACS, Stress Test (PubMed Search)

Posted: 2/23/2014 by Ali Farzad, MD (Updated: 3/23/2014)
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Over-reliance on stress tests is a common reason for misdiagnosis or delays in diagnosis in patients with ACS.
 
The utility of a recent negative stress test is limited when it is used to determine the risk for an ACS in patients presenting to the emergency department with symptoms of cardiac ischemia. 
 
Several studies, including a meta analysis, show that while a positive stress test can be useful in determining the next appropriate step of a patient's care, a negative stress test may not be as useful.
 
ED patients who bounceback after a negative stress test, represent a much higher risk population that may be at the same risk for ACS as those without previous testing.
 
Bottom Line:
No test is capable of reliably stratifying a patient’s risk to zero. If you are concerned about an ED chest pain patient with a HPI suggestive of ACS, treat conservatively and do not be misled by a recent negative stress test.
 
Bonus:
Working in an observation unit and don't know what stress test to order? Check out Dr. Mattu's lecture Non-invasive cardiac stress testing: What every emergency physician needs to know (Need EmedHome subscription for link to work).

 

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Category: Cardiology

Title: New TWI in aVL

Keywords: ECG, STEMI, aVL (PubMed Search)

Posted: 2/9/2014 by Ali Farzad, MD (Updated: 3/23/2014)
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The importance of new ST-segment depressions (STD) and/or T wave inversions (TWI) in lead aVL have not been emphasized or well recognized across specialties. Computer-assisted ECG readings typically report these findings as normal or nonspecific. 

There is growing evidence that changes in lead aVL are abnormal, and that paying attention to that lead can be clinically useful. Reciprocal changes presenting as STD or TWI in lead aVL may be indicative of a significant coronary artery lesion and can sometimes be the only ECG manifestation of acute MI.  

STD in lead aVL is considered a sensitive marker for early inferior STEMI, and has been shown to help differentiate STEMI from pericarditis. Another recent retrospective study suggests that TWI in aVL might be associated with significant LAD lesions. 

Bottom Line: Paying close attention to subtle changes and abnormalities in lead aVL may help in early identification and initiation of therapy for patients who are having an acute MI.  

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Attachments

TWI_in_aVL.pdf (112 Kb)


Category: Cardiology

Title: Extremely Fast & Wide Complex Regular Tachycardia

Keywords: Wide complex tachycardia, ventricular tachycardia (PubMed Search)

Posted: 1/26/2014 by Ali Farzad, MD (Updated: 3/23/2014)
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Question

A 48 year old woman has acute chest pain and palpitations over the past several hours. She has felt similar palpitations in the past but never sought medical attention. She arrives to your ED alert and anxious. HR = 270, BP=130/100. ECG is below. What’s the diagnosis and treatment?

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Attachments

JEM.WCT.Jan14.pdf (1,636 Kb)


Category: Cardiology

Title: Origin of premature ventricular beats

Keywords: PVC, Premature ventricular beats, Premature ventricular complexes (PubMed Search)

Posted: 1/12/2014 by Ali Farzad, MD (Updated: 3/10/2014)
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Differentiation between right and left ventricular origin of premature beats can be useful clinically.

 
The origin of ectopic ventricular beats are recognized best in lead V1 (oriented to differentiate right vs. left sided cardiac activity).
 
  • PVCs arising from the right ventricle have a left bundle branch block morphology (dominant S wave in V1)

  • PVCs arising from the left ventricle have a right bundle branch block morphology (dominant R wave in V1)

Left Ventricular premature beats are more often associated with heart disease and may precipitate ventricular fibrillation, whereas right ventricular premature beats are commonly seen in individuals with normal hearts. 

 

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Category: Cardiology

Title: How to measure ST elevation

Keywords: ST-elevation, Cardiology, MI (PubMed Search)

Posted: 12/29/2013 by Ali Farzad, MD (Updated: 3/10/2014)
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There is debate and confusion regarding where and how to measure ST elevation (STE). Do you measure the STE at the J-point? Or at 40 msec after the J-point? And how much STE is considered significant? The current guidelines have clarified this issue.

 - STE should be measured at the J-point.

STEMI is defined by STE ≥ 1 mm in at least 2 contiguous leads, with the exception of leads V2-V3.

STEMI is defined by STE ≥ 2 mm in leads V2-V3 in men.

STEMI is defined by STE ≥ 1.5 mm in leads V2-V3 in women.

For more cardiology pearls from the 2013 literature , check out Amal Mattu's Articles You've Gotta Know!

 

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Category: Cardiology

Title: The HEART score for ED patients with Chest Pain

Keywords: ACS, Chest Pain, HEART score (PubMed Search)

Posted: 12/8/2013 by Ali Farzad, MD (Updated: 3/10/2014)
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The diagnosis of non-STE ACS can be difficult to exclude in ED patients with chest pain. Consequently, over-diagnosis and unnecessary treatment are common. Risk stratification tools (ie. TIMIGRACE) have been created to help risk stratify ACS patients and predict mortality. However, they are of limited utility in the ED and do not effectively differentiate low to intermediate risk patients in all-comers with chest pain.  
 
The HEART score was recently prospectively validated in an ED population and was able to quickly and reliably predict risk of major adverse cardiac events (MACE - AMI, PCI, CABG, & Death). 
  • 5 practical considerations (History, ECG, Age, Risk factors, & Troponin) are scored (0,1,or 2 points each) depending on the extent of the abnormality.
  • A HEART score (0-10) can be quickly determined without complex calculations
  • Low scores (0-3) exclude short term MACE with >98% certainty
  • High scores (7-10) have high (>50%) MACE rates
  • The HEART score performed significantly better than TIMI and GRACE scores 

Bottom-line: The HEART score can help to objectively risk stratify ED patients with chest pain into low, intermediate, and high risk groups. Using the HEART score can also facilitate more efficient and effective communication with colleagues.

 

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Attachments

International_Journal_of_Cardiology_2013_Backus.pdf (371 Kb)

Neth_Heart_J_2008_Six.pdf (144 Kb)


Category: Cardiology

Title: Too early to give hypothermia the cold shoulder

Keywords: Therapeutic Hypothermia, ROSC, Cardiac Arrest, Resuscitation (PubMed Search)

Posted: 11/23/2013 by Ali Farzad, MD (Emailed: 11/24/2013) (Updated: 3/10/2014)
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Hyperthermia after resuscitation from cardiac arrest is associated with poor outcomes and death. Induced mild hypothermia gained widespread use after two RCT's from 2002 (n=352) showed improved survival & neurological outcomes for select patients with OHCA. 
 
In a new RCT (n=939), patients with ROSC after arrest were assigned to targeted temperature management at either 33°C or 36°C. Survival (51%) and a good neurologic outcome (47 to 48%) did not differ significantly between groups. However, cooling to 36°C is not the same as not regulating temperature and allowing hyperthermia. 
 
In contrast to a decade ago, one half instead of one third of these patients can expect to survive hospitalization. Paying attention to temperature makes survival more likely than death when a patient is hospitalized after cardiac arrest. 
 

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Attachments

N_Engl_J_Med_2013_Nielsen.pdf (497 Kb)

N_Engl_J_Med_2013_Rittenberger.pdf (317 Kb)

N_Engl_J_Med_2002_Hypothermia_after_Cardiac_Arrest_Study_Group.pdf (172 Kb)

N_Engl_J_Med_2002_Bernard.pdf (102 Kb)

Resuscitation_2013_Gebhardt.pdf (551 Kb)


Category: Cardiology

Title: Diagnosis of STEMI in LBBB

Keywords: AMI, LBBB, Sgarbossa criteria (PubMed Search)

Posted: 11/9/2013 by Ali Farzad, MD (Emailed: 11/10/2013) (Updated: 3/10/2014)
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Diagnosis of STEMI in patients with LBBB can be challenging. Guidelines that previously recommended emergent reperfusion for these patients have been reconsidered to avoid inappropriate cath lab activation and fibrinolytic therapy.

The 2013 ACC/AHA STEMI guidelines no longer consider new or presumably new LBBB a STEMI equivalent. This dramatic change may prevent inappropriate therapy for some, but fail to help identify patients with LBBB who are having STEMI's. Delayed reperfusion in this population could be fatal and is estimated to affect 5,000-10,000 patients per year in the US alone.

The Sgarbossa ECG criteria are the most validated tool to aid in the diagnosis of STEMI in the presence of LBBB. A Sgarbossa score of ≥ 3 has high specificity (>98%) and positive predictive value for acute MI and angiography-confirmed coronary occlusion. The following algorithm has been recently proposed to identify the high-risk population in which reperfusion therapy would be denied by the 2013 STEMI guidelines.

Watch this video to review Sgarbossa criteria and the modified Sgarbossa rule.

 

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Attachments

American_Heart_Journal_2013_MD.pdf (726 Kb)


Category: Cardiology

Title: Marked First Degree AV Block

Keywords: AV Block (PubMed Search)

Posted: 10/27/2013 by Ali Farzad, MD (Updated: 3/10/2014)
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First-degree atrioventricular (AV) block is defined as an abnormally prolonged PR-interval >200ms. Although traditionally considered to be a benign clinical entity, not all first degree AV blocks are treated the same.  

Markedly prolonged PR-intervals (PR >300ms) can cause symptoms and hemodynamic compromise due to inadequate timing of atrial and ventricular contractions. Consider the following ECG from a 32 YOF with intermittent episodes of syncope and dizziness…

There is marked first degree AV block (PR=434 ms). When the PR-interval gets too long, AV dyssynchrony compromises ventricular filling and decreases cardiac output, similar to the so-called pacemaker syndrome.

Current ACC/AHA guidelines state that permanent pacemaker implantation is reasonable for marked first degree AV block with hemodynamic compromise or symptoms similar to those of pacemaker syndrome. (Class IIa, Level of Evidence B). The guidelines caution that pacemakers are not indicated in asymptomatic patients with isolated first degree AV block.

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Attachments

ACC:AHA_Pacemaker_Guidelines.pdf (1,524 Kb)

1st_Degree_AVB._Benign_or_Curable_Cardiac_Disease.pdf (247 Kb)


Category: Cardiology

Title: What's the ECG abnormality?

Keywords: Dyspnea, Chest Pain (PubMed Search)

Posted: 10/13/2013 by Ali Farzad, MD (Updated: 3/10/2014)
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Question

A 48 year-old female presents to the ED with progressive dyspnea and chest discomfort over the past 3 months. HR = 105, BP = 100/60 mmHg, with mild JVD on exam. Her ECG is shown below. What ECG abnormalites are present? What does your differential diagnosis include? What is the best initial diagnostic test?

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Attachments

ECGs_with_small_QRS_voltages.pdf (578 Kb)

Low_QRS_voltage_and_its_causes.pdf (108 Kb)


The primary goal in management of STEMI is rapid coronary revascularization. STEMI's are occasionally complicated by ventricular fibrillation (VF) arrest. High quality chest compressions and early defibrillation will improve survival. But what can be done in cases where conventional ACLS measures fail and patients have shock-refractory VF?

Some have suggested that emergent PCI with ongoing CPR en route may be beneficial. This option may be considered in close consultation with cardiology if the arrest is thought to be driven by ongoing ischemia and infarction. However, definitive data is lacking and this has only been described in a handful of case reports.

There may also be a role for venoarterial ECMO to aid in perfusion of vital organs and limit the risk of multisystem organ failure. The ECMO circuit can also help facilitate therapeutic hypothermia after the culprit vessel(s) is revascularized and rhythm is restored. 

Chances for survival are highest in younger patients, those that do not have chronic illnesses, and those who received immediate CPR after arrest. 

Summary:

Consider emergent consultation for salvage PCI and ECMO in select cases of shock-refractory ventricular fibrillation associated with STEMI

 

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Attachments

NEJM-Refractory_VF_arrest.pdf (800 Kb)


Category: Cardiology

Title: Colchicine for treatment of acute pericarditis

Keywords: Acute Pericarditis, Colchicine (PubMed Search)

Posted: 9/15/2013 by Ali Farzad, MD (Updated: 3/10/2014)
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Colchicine is known to be effective in treatment of recurrent pericarditis, but until recently its efficacy during the first attack of acute pericarditis has been uncertain.

A recent multicenter, double-blinded, RCT of patients with acute pericarditis found colchicine to be effective in reducing the rate of incessant or recurrent pericarditis (primary outcome), as well as the rate of hospitalization. Here are some highlights:

  •  240 patients with acute pericarditis received conventional therapy (aspirin or ibuprofen), half of them were randomized to also get colchicine, the other half to placebo for 3 months
  • Incessant or recurrent pericarditis: 16%  in the colchicine group versus 37% in the control group (relative risk reduction=0.56; CI 0.30-0.72; NNT =4; p < 0.001)
  • Symptom persistence at 72 hours, recurrences per patient, and hospitalization rate were all significantly reduced in the colchicine group
  • There were no significant differences in adverse effects or discontinuation of the study drugs

Bottom-line:

Colchicine is a safe and effective drug for the treatment of acute pericarditis. Consider adding colchicine to conventional therapies to reduce duration of symptoms, recurrences, and rate of hospitalization.

 
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Attachments

NEJM-Colchicine_RCT.pdf (527 Kb)


Category: Cardiology

Title: Asymptomatic markedly elevated blood pressure in the ED

Keywords: Hypertension (PubMed Search)

Posted: 9/1/2013 by Ali Farzad, MD (Updated: 3/10/2014)
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Adult ED patients are commonly found to have markedly elevated blood pressures (>160/100) without any signs or symptoms of acute organ injury (ie, cardiovascular, renal, or neurological).  

A recently revised ACEP clinical policy aims to guide emergency physicians in the evaluation and management of such patients.

They make the following recommendations (Level C):

  • Routine screening tests (ie, CXR, ECG, UA, BMP) do not reduce adverse outcomes and are not required from the ED.
  • Initiation of medical treatment does not reduce adverse outcomes and is not required in the ED.
  • Patients with persistently elevated blood pressure should be referred for primary care follow-up.
  • In select patient populations (eg. poor access to care), a screening creatinine level may identify renal injury that may alter disposition.
  • If medication is started in the ED, the goal should be to facilitate gradual long-term control. Rapidly lowering blood pressure may be harmful.

Bottom-line:

There's little evidence to guide the decision of which patients with markedly elevated blood pressures to test or treat in the ED. This new clinical policy suggests that routine screening and treatment is not required. Asymptomatic patients should be referred for close follow-up, but consider a BMP in patients with poor follow up. 

 

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Attachments

Ann_Emerg_Med_2013_Wolf.pdf (186 Kb)