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The single most important talk of your career begins in...
5 Years
Cardiology Review
Wieters
From @srrezaie
No Disclosures
J. Scott Wieters MD @EMedCoach
Wieters@gmail.com
5 Years
1. Avoid Pitfalls in DX Aortic Dissection 2. Diagnose the subtle STEMI 3. Manage Ventricular Dysrhythmias 4. Recognize and Treat Pericarditis 5. Admit less Syncope Patients
Diercks DB, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection. Annals of Emergency Medicine 2015. PMID 25529153
Aortic Dissection
CDRD-dimer
USCTA
Diercks DB, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection. Annals of Emergency Medicine 2015. PMID 25529153
Aortic Dissection
CDRD-dimer
USCTA2017
LLSA
I’m Better At Diagnosing STEMI
5 Years
I’ve still got a LOT to learn…
STEMI Longer QTc
more STE V3 Smaller Rv4
BER Shorter QTc Less STE V3 Large Rv4
STEMI
BER
STEMI
BER
Longer QTc
Less STE v3
Smaller Rv4
Shorter QTc
More STE v3
Larger Rv4
STEMI
BER
QTc- 411
ST V3- 1.2
R v4- 7
QTc- 371
ST V3- 4
R v4- 19
STE 60 V3
QTc RAV4formula
value
2 460 13 25.294
>23.4 Sens. & Spec. for STEMI
http://hqmeded-ecg.blogspot.com/p/rules-equations.html
QTc- 411ST V3- 1.2
R v4- 6
QTc- 371ST V3- 4
R v4- 19
STEMI
BER
24
20.5
Value >23.4 predicts STEMI
Manage Ventricular
Dysrhythmias
5 Years
Electricity
Drugs
And
Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2016;
Procainamide Amiodarone
PTS 33 29Adverse. Events 18% 31%MACE 9% 41%
CARDIOVERT 67% 38%
Procamio
Amiodarone Lidocaine Placebo Study
Kudenchuk PJ et al. Amiodarone, Lidocaine, or Placeboe in Out-of-Hospital Cardiac Arrest. NEJM 2016.
PTS DC MR<3
Amio. 974 24.4% 18.8%
Lido. 993 23.7% 17.5%
Placebo 1059 21.0% 16.6%
Kudenchuk PJ et al. Amiodarone, Lidocaine, or Placeboe in Out-of-Hospital Cardiac Arrest. NEJM 2016.
Amiodarone Lidocaine Placebo Study
• pic of pads coming at patient.
Cabañas JG, Myers JB, Williams JG, De Maio VJ, Bachman MW. Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Report of Ten Cases. Prehosp Emerg Care. 2015 January-March;19(1):126-130. Epub 2014 Sep 22. PubMed PMID: 25243771.
10 Pts Failed 5 shocks
DSD 7/10 Converted
NONE Survived DC
7 Pts Failed 5 shocks
M.A. Merlin, A. Tagore, R. Bauter, F.H. ArshadA case series of double sequence defibrillation Prehosp Emerg Care (2016), pp. 1–4
M.A. Merlin, A. Tagore, R. Bauter, F.H. Arched vA case series of double sequence defibrillation Prehosp Emerg Care (2016), pp. 1–4
Converted 5/7
Survived DC 3/7
CPC 1 2/7
7 Pts Failed 5 shocks
Cortez E et al. Use of Double Sequential External Defibrillation for Refractory Ventricular Fibrillation During Out-of-Hospital Cardiac Arrest. Resuscitation 2016. S0300-9572(16): 30398 – 7. [Epub ahead of print] PMID: 27521470
12 Pts Failed 5 shocks
Cortez E et al. Use of Double Sequential External Defibrillation for Refractory Ventricular Fibrillation During Out-of-Hospital Cardiac Arrest. Resuscitation 2016. S0300-9572(16): 30398 – 7. [Epub ahead of print] PMID: 27521470
Converted 9/12
ROSC 3/12
Survived DC
3/12
CPC 1 2/12
Elliot M. Ross, Theodore T. Redman, Stephen A. Harper, Julian G. Mapp, David A. Wampler, David A. Miramontes, Dual defibrillation in out-of-hospital cardiac arrest: A retrospective cohort analysis, Resuscitation, Volume 106, September 2016, Pages 14-17,
279 Recurrant VF
50 DSD 229 SD
28%ROSC 38%ROSC
6%CPC1 11% CPC1
Summary?
Refractory Vfib May respond to
DSD?
• pic of pads coming at patient.
Esmolol?
41 Pts with Ref. Vfib
ESMOLOL NADA p
PTS 16 25 0.007
ROSC/ICU 56% 16% 0.38
CPC1-2 18% 8% 0.38
Lee YH et al. Refractory Ventricular Fibrillation Treated with Esmolol. Resuscitation 2016. [Epub Ahead of Print]. PMID: 27523955
Electricity
Drugs
AndDSD
Esmolol
Refractory Vfib?
Pericarditis?
5 Years
CASEBP 150/92
P 105
RR 35
Sat 87%
T 98.7F
In Your ED
Pericarditis
Clinical?
Rub?
EKG?
Markers?
ECHO?
STEMI?Is there ST depression in a lead other than AVR or V1?
Is there convex up or horizontal ST elevation?
Is there ST elevation greater in III than II?
No PR depression in multiple leads…
Mattu Pericarditis 2012
Reciprocal changes
PR Depression
Diffuse ST elevation <5mm
ST to T wave >0.25
PR Elevation
ST II>III
Pericarditis
Repol. v. Pericarditis
ST = 3 mm
T = 6 mm
ST / T ratio = 50%
The ST / T ratio > 25%= pericarditis.
www.lifeinthefastlane.com
63 / = 50%
ST = 1 mm T = 6 mm ST / T ratio = 16% The ST / T ratio < 25%= BER
www.lifeinthefastlane.com
61 / = 16%
Repol. v. Pericarditis
Fish Hook = BER
www.lifeinthefastlane.com
Reciprocal changes
PR Depression
Diffuse ST elevation <5mm
ST to T wave >0.25
PR Elevation
ST II>III
Pericarditis
Which Meds?
“When I get a headache, I take two aspirin and I keep away from the children. Just like the Bottle says”
NSAIDS?
Steroids?
Imazio M, Adler Y. Treatment with aspirin, NSAID, corticosteroids, and colchicine in acute and recurrent pericarditis.
Heart Fail Rev 2013;18:355–60.
Colchicine?
-240 participants -PC DB RCT
-Colchicine vs Placebo
ICAP
Imazio M, et al. “A Randomized Trial of Colchicine for Acute Pericarditis”. The New England Journal of Medicine. 2013. 369(16):1522-1528. PMID:23992557
2016 LLSA
ICAP
Imazio M, et al. “A Randomized Trial of Colchicine for Acute Pericarditis”. The New England Journal of Medicine. 2013. 369(16):1522-1528. PMID:23992557
72 hrs 18 moColchicine
ASA and NSAID 19% 9%
placebo ASA and NSAID 40% 21%
-564 participants -four RCTs
Alabed, Samer, Cabello, Juan B, Irving, Greg J, Qintar, Mohammed, Burls, Amanda. Colchicine for pericarditis. (Protocol) Cochrane Database of
Systematic Reviews 2014, Issue 8.
Cochrane 2014
“Colchicine, reduces pericarditis recurrences”
Alabed, Samer, Cabello, Juan B, Irving, Greg J, Qintar, Mohammed, Burls, Amanda. Colchicine for pericarditis. (Protocol) Cochrane Database of
Systematic Reviews 2014, Issue 8.
Cochrane 2014
Colchicine for
pericarditis.
Meta-Anaylsis 2016
Papageorgiou N, Briasoulis A, Lazaros G, Imazio M, Tousoulis D. Colchicine for prevention and treatment of cardiac diseases: a meta-analysis. Cardiovasc Ther. 2016 Aug 31. doi: 10.1111/1755-5922.12226. [Epub ahead of print] PubMed PMID:27580061.
17 Studies 2,000 Pts
Colchicine
Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA. 2015 Oct 13;314(14):1498-506. doi:10.1001/jama.2015.12763. Review. Erratum in: JAMA. 2015 Nov 10;314(18):1978.JAMA. 2016 Jan 5;315(1):90.
Reduced A. Fib In Pericarditis
-1-2mg day one -Then 0.5-1 mg/day 3mo
Avoid Colchicine in:
- Renal Failure - Hepatic dysfunction - Pregnant or Lactating - Immunosuppression
Gastric Protection?
-Master the EKG -ASA -NSAIDS -Colchicine -Avoid Steroids
Summary Pericarditis
1(800) RIO-DROPPrehospital Services
Prehospital Services1(800) RIO-DROP
Syncope
5 Years
15%
Mattu
SAH
PEEctopic
ADAAA
ACS
Syncope
Sens. Spec. NPV PPV
San Fran.
87% 52% 97% 19%
Boston 100% 57% 100% 44%
OESIL 98% 28% 98% 28%
EGSYS 95% 61% 99% 33%https://www.aliem.com/2013/management-of-syncope-aka-done-fell-out/
Rules, Rules, Rules…
Level A:
H&P to Risk Stratify ECG
ACEP on Syncope
High risk of AE: Older Structural HD CAD
ACEP on Syncope
Low risk of AE: Young Nonexertional NO CVD NO Comorbidities NO Fam Hx SCD
ACEP on Syncope
Admit CHF, Ischemia or structural heart disease Older age (>70) and associated co-morbidities Abnormal ECG HCT < 30
ACEP on SyncopeLevel C:
Lab ECHO
CT
better chart
Numeroso F, Mossini G, Giovanelli M, Lippi G, Cervellin G. Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk:
Results from the IRiS (Intermediate-Risk Syncope) Study. Acad Emerg Med. 2016 Aug;23(8):941-8. doi: 10.1111/acem.13013. Epub 2016 Aug 1. PubMed PMID: 27178670.
Numeroso F, Mossini G, Giovanelli M, Lippi G, Cervellin G. Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk:
Results from the IRiS (Intermediate-Risk Syncope) Study. Acad Emerg Med. 2016 Aug;23(8):941-8. doi: 10.1111/acem.13013. Epub 2016 Aug 1. PubMed PMID: 27178670.
IRiS
Numeroso F, Mossini G, Giovanelli M, Lippi G, Cervellin G. Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk:
Results from the IRiS (Intermediate-Risk Syncope) Study. Acad Emerg Med. 2016 Aug;23(8):941-8. doi: 10.1111/acem.13013. Epub 2016 Aug 1. PubMed PMID: 27178670.
Decomp. HD Fam. Hx SCD Bad Story Valvular HD Bad EKG
HIGH Risk
Numeroso F, Mossini G, Giovanelli M, Lippi G, Cervellin G. Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk:
Results from the IRiS (Intermediate-Risk Syncope) Study. Acad Emerg Med. 2016 Aug;23(8):941-8. doi: 10.1111/acem.13013. Epub 2016 Aug 1. PubMed PMID: 27178670.
Decompensated HD Fam. Hx SCD Exertion/Supine Palpitations/CP Valvular HD Bad EKG
Hx CHF?Age?
Hx CAD?
Numeroso F, Mossini G, Giovanelli M, Lippi G, Cervellin G. Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk:
Results from the IRiS (Intermediate-Risk Syncope) Study. Acad Emerg Med. 2016 Aug;23(8):941-8. doi: 10.1111/acem.13013. Epub 2016 Aug 1. PubMed PMID: 27178670.
347
243 95
28.4%0.8%
Int. High
IRiS
MACE MACE
Numeroso F, Mossini G, Giovanelli M, Lippi G, Cervellin G. Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk:
Results from the IRiS (Intermediate-Risk Syncope) Study. Acad Emerg Med. 2016 Aug;23(8):941-8. doi: 10.1111/acem.13013. Epub 2016 Aug 1. PubMed PMID: 27178670.
IRiS
Discharge?
Costantino G, Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in theemergency department. Eur Heart J. 2016 May 14;37(19):1493-8. doi:10.1093/eurheartj/
ehv378. Epub 2015 Aug 4. PubMed PMID: 26242712; PubMed Central PMCID: PMC4872282.
International Workshop Syncope In ED Consensus
Costantino G, Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in theemergency department. Eur Heart J. 2016 May 14;37(19):1493-8. doi:10.1093/eurheartj/
ehv378. Epub 2015 Aug 4. PubMed PMID: 26242712; PubMed Central PMCID: PMC4872282.
“Difficult to gain Consensus”
Costantino G, Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in theemergency department. Eur Heart J. 2016 May 14;37(19):1493-8. doi:10.1093/eurheartj/
ehv378. Epub 2015 Aug 4. PubMed PMID: 26242712; PubMed Central PMCID: PMC4872282.
“Admit Intermediate and High risk patients.”
Summary1. Avoid Pitfalls in DX Aortic Dissection 2. Diagnose the subtle STEMI 3. Manage Ventricular Dysrhythmias 4. Recognize and Treat Pericarditis 5. Admit less Syncope Patients
@EMedCoach
Wieters@gmail.com
5 Years?
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