[Show abstract][Hide abstract] ABSTRACT: Introduction: Copeptin has demonstrated a role in early rule out for acute myocardial infarction in combination with a negative troponin. However, the value of copeptin in patients with a positive troponin is not established.
Hypothesis: The addition of a baseline copeptin at chest pain presentation will improve risk stratification in patients with mild troponin elevation.
Methods: The multi-center CHOPIN trial enrolled 2071 acute chest pain patients. All subjects with ST segment elevations were excluded from this analysis. Of the remaining patients, 124 had a mildly elevated troponin (defined by <2x URL) and were included in the study cohort. Baseline cTnI and copeptin levels were drawn on presentation, and another cTnI at 2 hours. Copeptin ≤14 pmol/l and troponin deltas ≤10% from baseline were considered positive. Two independent blinded cardiologists adjudicated AMI diagnosis. The value of a baseline copeptin in this cohort was assessed using AMI incidence, odds ratio, sensitivity, and negative predictive value (NPV).
Results: Of the 124 patients in the study cohort, 73 (59%) had an elevated copeptin and an associated AMI incidence of 25% (18 AMIs). The remaining 51 patients (41%) were copeptin negative and diagnosed with 3 AMIs, an incidence of 5.9% (p = 0.006, figure 1). A positive copeptin increased the likelihood of AMI diagnosis with an odds ratio of 5.3 (95% CI: 1.5-19.2). The sensitivity and NPV for AMI were 86% and 94%, both of which were higher than the delta troponin (table 1). When an initial copeptin was combined with the delta troponin the sensitivity and NPV for AMI improved to 100%.
Conclusion: Use of copeptin in chest pain patients with mild troponin elevation provides further risk stratification. The combination of copeptin with a delta troponin may aid in earlier AMI rule out in this subset of patients. This approach could be especially relevant as the increasing use of high sensitivity troponin assays leads to greater rates of mild troponin elevations.
[Show abstract][Hide abstract] ABSTRACT: We investigated absolute and relative cardiac troponin I (TnI) delta changes, optimal sampling protocols, and decision thresholds for early diagnosis of myocardial infarction (MI). Serial cardiac biomarker values demonstrating a rise and/or fall define MI diagnosis; however the magnitude of change, timing, and diagnostic accuracy of absolute versus relative (percentage) deltas remains unsettled.
[Show abstract][Hide abstract] ABSTRACT: To compare emergency department TnI serial sampling intervals, determine optimal diagnostic thresholds, and report representative diagnostic performance characteristics for early rule-in and rule-out of MI.
[Show abstract][Hide abstract] ABSTRACT: Non-invasive, continuous hemodynamic monitoring is entering the clinical arena. The primary objective of this study was to test the feasibility of such monitoring in a pilot sample of Emergency Department (ED) stroke patients. Secondary objectives included analysis of hemodynamic variability and correlation of continuous blood pressure measurements with standard measurements.
The western journal of emergency medicine 07/2014; 15(4):345-50.
[Show abstract][Hide abstract] ABSTRACT: Abstract: Study Objectives: To compare the safety and efficacy of US Food and Drug Administration (FDA)-recommended doses of labetalol and nicardipine for hypertension (HTN) management in a subset of patients with renal dysfunction (RD). Design: Randomized, open label, multicenter prospective clinical trial. Setting: Thirteen United States tertiary care emergency departments. Patients or Participants: Subgroup analysis of the Evaluation of IV Cardene (Nicardipine) and Labetalol Use in the Emergency Department (CLUE) clinical trial. The subjects were 104 patients with RD (ie, creatinine clearance < 75 mL/min) who presented to the emergency department with a systolic blood pressure (SBP) ≥ 180 mmHg on 2 consecutive readings and for whom the emergency physician felt intravenous antihypertensive therapy was desirable. Interventions: The FDA recommended doses of either labetalol or nicardipine for HTN management. Measurements: The number of patients achieving the physician’s predefined target SBP range within 30 minutes of treatment. Results: Patients treated with nicardipine were within target range more often than those receiving labetalol (92% vs 78%, P = 0.046). On 6 SBP measures, patients treated with nicardipine were more likely to achieve the target range on either 5 or all 6 readings than were patients treated with labetalol (46% vs 25%, P = 0.024). Labetalol patients were more likely to require rescue medication (27% vs 17%, P = 0.020). Adverse events thought to be related to either treatment group were not reported in the 30-minute active study period, and patients had slower heart rates at all time points after 5 minutes (P < 0.01). Conclusions: In severe HTN with RD, nicardipine-treated patients are more likely to reach a target blood pressure range within 30 minutes than are patients receiving labetalol. Clinical Implications: Within 30 minutes of administration, nicardipine is more efficacious than labetalol for acute blood pressure control in patients with RD.
Postgraduate Medicine 07/2014; 126(4):124-130. · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Dyspnea is the most common symptom in acute heart failure (AHF), yet how to best measure it has not been well defined. Prior studies demonstrate differences in dyspnea improvement across various measurement scales, yet these studies typically enroll patients well after the emergency department (ED) phase of management.Objectives
The aim of this study was to determine predictors of early dyspnea improvement for three different, commonly used dyspnea scales (i.e., five-point absolute Likert scale, 10-cm visual analog scale [VAS], or seven-point relative Likert scale).Methods
This was a post hoc analysis of URGENT Dyspnea, an observational study of 776 patients in 17 countries enrolled within 1 hour of first physician encounter. Inclusion criteria were broad to reflect real-world clinical practice. Prior literature informed the a priori definition of clinically significant dyspnea improvement. Resampling-based multivariable models were created to determine patient characteristics significantly associated with dyspnea improvement.ResultsOf the 524 AHF patients, approximately 40% of patients did not report substantial dyspnea improvement within the first 6 hours. Baseline characteristics were similar between those who did or did not improve, although there were differences in history of heart failure, coronary artery disease, and initial systolic blood pressure. For those who did improve, patient characteristics differed across all three scales, with the exception of baseline dyspnea severity for the VAS and five-point Likert scale (c-index ranged from 0.708 to 0.831 for each scale).Conclusions
Predictors of early dyspnea improvement differ from scale to scale, with the exception of baseline dyspnea. Attempts to use one scale to capture the entirety of the dyspnea symptom may be insufficient.ResumenAntecedentesLa disnea es el síntoma más frecuente en la insuficiencia cardiaca aguda (ICA), sin embargo no ha sido bien definida la mejor manera de medirla. Estudios previos demuestran diferencias en la mejoría de la disnea a través de varias escalas de medida, sin embargo estos estudios suelen reclutar pacientes bastante después de la fase de manejo en el SU.ObjetivosEl objetivo de este estudio fue determinar los predictores precoces de mejoría de la disnea para tres escalas de disnea diferentes frecuentemente utilizadas (escala Likert absoluta de 5 puntos, escala visual analógica [EVA] de 10 cm o escala Likert relativa de 7 puntos).MétodosSe trata de un análisis post hoc del estudio observacional Disnea URGENTE, que reclutó 776 pacientes dentro de la primera hora tras la primera valoración médica en 17 países. Los criterios de inclusión fueron amplios para reflejar la práctica clínica en el mundo real. La literatura previa documentó la definición a priori de la mejoría significativa de disnea. Se crearon modelos multivariables basados en el remuestreo para determinar las características de los pacientes significativamente asociadas con la mejoría de la disnea.ResultadosDe los 524 pacientes con ICA, aproximadamente un 40% de los pacientes no documentaron una mejoría sustancial de la disnea en las 6 primeras horas. Las características basales fueron similares entre los que mejoraron y los que no, aunque hubo diferencias en la historia de insuficiencia cardiaca, enfermedad coronaria y presión arterial sistólica inicial. Para aquéllos que mejoraron, las características del paciente difirieron en las tres escalas, con la excepción de la gravedad de la disnea basal para la EVA y en la escala Likert de 5 puntos (el índice-c varió desde 0,708 hasta 0,831 para cada escala).ConclusionesLos predictores de la mejoría precoz de disnea difieren dependiendo de la escala, con la excepción de la disnea basal. Los intentos para utilizar una sola escala para categorizar la totalidad del síntoma disnea pueden ser insuficientes.
Academic Emergency Medicine 06/2014; 21(6). · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Elevated blood pressure is present in more than 60% of patients with acute stroke. Moderate to severe hypertension affects stroke outcomes, yet the optimal management has been a gray area in the care of such patients. Although new data are changing the approach, particularly for hemorrhagic events, significant questions remain. This article presents the latest evidence on hypertension in the setting of ischemic and hemorrhagic stroke and highlights management considerations that are relevant to emergency medicine.
Annals of emergency medicine 04/2014; · 4.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Despite its relatively common occurrence and life-threatening potential, the management of angioedema in the emergency department (ED) is lacking in terms of a structured approach. It is paramount to distinguish the different etiologies of angioedema from one another and more specifically differentiate histaminergic-mediated angioedema from bradykinin-mediated angioedema, especially in lieu of the more novel treatments that have recently become available for bradykinin-mediated angioedema. With this background in mind, this consensus parameter for the evaluation and management of angioedema attempts to provide a working framework for emergency physicians (EPs) in approaching the patient with angioedema in terms of diagnosis and management in the ED. This consensus parameter was developed from a collaborative effort among a group of EPs and leading allergists with expertise in angioedema. After rigorous debate, review of the literature, and expert opinion, the following consensus guideline document was created. The document has been endorsed by the American College of Allergy, Asthma & Immunology (ACAAI) and the Society for Academic Emergency Medicine (SAEM).ResumenA pesar de su ocurrencia relativamente común y su potencial riesgo vital, el manejo del paciente con angioedema en el servicio de urgencias está falto de una aproximación estructurada. Es primordial distinguir las diferentes etiologías del angioedema y más específicamente diferenciar el angioedema mediado por histamina del mediado por bradicinina, especialmente en relación con los tratamientos que recientemente están disponibles para el angioedema mediado por bradicinina. Con este escenario en mente, este parámetro consenso para la evaluación y el manejo del angiodema intenta proporcionar un marco de trabajo para los urgenciólogos en la aproximación del paciente con angiodema en términos de diagnóstico y tratamiento en el servicio de urgencias. Este esquema consenso fue desarrollado a través de un esfuerzo de colaboración entre un grupo de urgenciólogos y alergólogos expertos líderes en angiodema. Tras un riguroso debate, una revisión de la literatura y la opinión de los expertos, se creó el siguiente documento de guía clínica de consenso. En reconocimiento a la importancia de este tema, este documento de consenso ha sido respaldado por el American College of Allergy, Asthma, and Immunology (ACAAI) y la Society for Academic Emergency Medicine (SAEM).
Academic Emergency Medicine 04/2014; 21(4). · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Patients with frequent asthma exacerbations resulting in emergency department (ED) visits are at increased risk for future exacerbations. We examined the ability of one dose of benralizumab, an investigational anti-interleukin-5 receptor α monoclonal antibody, to reduce recurrence following acute asthma exacerbations.
In this randomized, double-blind, placebo-controlled study, eligible subjects presented to the ED with an asthma exacerbation, had partial response to treatment, and ≥ 1 additional exacerbation within the previous year. Subjects received one intravenous infusion of placebo (n = 38) or benralizumab (0.3 mg/kg, n = 36 or 1.0 mg/kg, n = 36) added to outpatient management. The primary outcome was the proportion of subjects with ≥ 1 exacerbation at 12 weeks in placebo vs the combined benralizumab groups. Other outcomes included the time-weighted rate of exacerbations at week 12, adverse events, blood eosinophil counts, asthma symptom changes, and healthcare resource utilization.
The proportion of subjects with ≥ 1 asthma exacerbation at 12 weeks was not different between placebo and the combined benralizumab groups (38.9% vs 33.3%; P= 0.67). However, compared with placebo, benralizumab reduced asthma exacerbation rates by 49% (3.59 vs 1.82; P= 0.01), and exacerbations resulting in hospitalization by 60% (1.62 vs 0.65; P= 0.02) in the combined groups. Benralizumab reduced blood eosinophil counts but did not affect other outcomes, while demonstrating an acceptable safety profile.
When added to usual care, one dose of benralizumab reduced the rate and severity of exacerbations experienced over 12 weeks by subjects who presented to the ED with acute asthma.
The American Journal of Emergency Medicine. 01/2014;
[Show abstract][Hide abstract] ABSTRACT: Clinical problem
This a case of non-traumatic shoulder pain initially diagnosed on x-ray as an anterior dislocation. The patient was on anticoagulants and in actuality had severe hemarthrosis that caused the subluxation. Attempts to reduce the dislocation in this situation might have resulted in worsening of the intra-articular bleed.
Analysis of literature review
There has been only one similar reported case in the European Journal of Emergency Medicine in 2013 of a 53-year-old woman who was thought to have a nontraumatic anterior shoulder dislocation and attempts were unsuccessful at reduction. Definitive therapy involved hemarthrosis aspiration.
Others have reported spontaneous hemarthrosis due to anticoagulants, however, only one has reported an initial mistaken joint dislocation diagnosis.
Non-traumatic hemarthrosis do occur in patients on anticoagulant therapy and it is important to recognize that this can be misdiagnosed as a joint dislocation requiring reduction. In a patient who is on anticoagulants presenting with nontraumatic joint pain and anterior shoulder or possibly other dislocations on plain radiographs, it is pertinent to consider hemarthrosis.
The American Journal of Emergency Medicine. 01/2014;
[Show abstract][Hide abstract] ABSTRACT: Although most cases of anaphylaxis are treated in the emergency department (ED), personnel may not immediately recognize anaphylaxis based on presenting symptoms because it has a wide range of clinical manifestations and variable progression. When symptoms happen to be atypical or mild and when no trigger is identified, the diagnosis of anaphylaxis can be challenging. Underdiagnosis of anaphylaxis can lead to delayed use of appropriate first-line epinephrine in favor of treatments that should be used as adjunctive only. Even when anaphylaxis is recognized, the choice between an epinephrine autoinjector or epinephrine ampule can still present a challenge. Treatment of anaphylaxis in the ED should include a combination of intramuscular epinephrine, supplemental oxygen, and intravenous fluids. If there is an incomplete response to the initial dose of epinephrine, additional doses or other measures may be considered. The most important management consideration is avoiding treatment delays, because symptoms can progress rapidly. Upon discharge from the ED, all patients with anaphylaxis should be given a prescription for at least 2 epinephrine autoinjectors, an initial emergency action plan, education about avoidance of triggers, and a referral to an allergist. A significant limitation of current studies is that clinical outcomes in anaphylaxis associated with established poor rates of diagnosis and use of recommended treatments are unclear; such trials must be conducted as supporting evidence for ED management guidelines for anaphylaxis.
The American journal of medicine 01/2014; 127(1):S34–S44. · 5.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Eight to ten million individuals are evaluated for chest pain (CP) in Emergency Departments (ED) in the United States each year. CP characteristics are an important factor used to help determine a diagnosis. We studied the relationship between the duration of CP and the diagnosis of acute myocardial infarction (AMI) in patients evaluated in the ED.
The study population consisted of a sub-group analysis of a previously published study. The survey population consisted of 1024 consecutive encounters of patients who were evaluated for possible ACS in the ED of Henry Ford Hospital between January and May of 1999, CP duration could be obtained in 426 who were included in this analysis.
Of the 426 patients included in the study, 38 (8.9%) had a final diagnosis of AMI, with a median CP duration of 120 minutes (interquartile range, 30-240 minutes), compared with 40 minutes (interquartile range, 6-180 minutes) in patients without AMI (p =0.003). In patients with CP duration less than 5 minutes, there were no AMIs and no deaths at 30 days. There were 10 patients dead at 30 days, with a median CP duration of 180 minutes (interquartile range, 120-1440 minutes) compared to 40 minutes (interquartile range, 10-180 minutes) in patients alive at 30 days (p = 0.011). A longer CP duration and ST depression of 1 mm of less were independently associated with a final diagnosis of AMI.
Patients with AMI have longer duration of CP than those without AMI; patients with CP of short duration, less than 5 minutes, are unlikely to have AMI and have a good prognosis at 30 days.
Critical pathways in cardiology 09/2013; 12(3):150-3.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to assess the impact of atrial fibrillation (AF) on the performance of mid-region amino terminal pro-atrial natriuretic peptide (MR-proANP) in comparison with the B-type peptides (BNP and NT-proBNP) for diagnosis of acute heart failure (HF) in dyspneic patients.
The effects of AF on the diagnostic and prognostic performance of MR-proANP in comparison with the B type natriuretic peptides have not been previously reported.
A total of 1,445 patients attending the emergency department with acute dyspnea had measurements taken of MR-proANP, BNP, and NT-proBNP values on enrollment to the BACH trial and were grouped according to presence or absence of AF and HF.
AF was present in 242 patients. Plasma concentrations of all three peptides were lowest in those with neither AF nor HF and AF without HF was associated with markedly increased levels (p < 0.00001). HF with or without AF was associated with a significant further increment (p < 0.00001 for all three markers). Areas under receiver operator characteristic curves (AUCs) for discrimination of acute HF were similar and powerful for all peptides without AF (0.893 to 0.912; all p < 0.001) with substantial and similar reductions (0.701 to 0.757) in the presence of AF. All 3 peptides were independently prognostic but there was no interaction between any peptide and AF for prediction of all-cause mortality.
AF is associated with increased plasma natriuretic peptide (MR-proANP, BNP and NT-proBNP) levels in the absence of HF. The diagnostic performance of all three peptides is impaired by AF. This warrants consideration of adjusted peptide thresholds for diagnostic use in AF and mandates the continued search for markers free of confounding by AF.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Most episodes of anaphylaxis are managed in emergency medical settings, where the cardinal signs and symptoms often differ from those observed in the allergy clinic. Data suggest that low recognition of anaphylaxis in the emergency setting may relate to inaccurate coding and lack of a standard, practical definition. OBJECTIVE: Develop a simple, consistent definition of anaphylaxis for emergency medicine providers, supported by clinically relevant consensus statements. DISCUSSION: Definitions of anaphylaxis and criteria for diagnosis from current anaphylaxis guidelines were reviewed with regard to their utilization in emergency medical settings. The agreed-upon working definition is: Anaphylaxis is a serious reaction causing a combination of characteristic findings, and which is rapid in onset and may cause death. It is usually due to an allergic reaction but can be non-allergic. The definition is supported by Consensus Statements, each with referenced discussion. For a positive outcome, quick diagnosis and treatment of anaphylaxis are critical. However, even in the emergency setting, the patient may not present with life-threatening symptoms. Because mild initial symptoms can quickly progress to a severe, even fatal, reaction, the first-line treatment for any anaphylaxis episode-regardless of severity-is intramuscular injection of epinephrine into the anterolateral thigh; delaying its administration increases the potential for morbidity and mortality. When a reaction appears as "possible anaphylaxis," it is generally better to err on the side of caution and administer epinephrine. CONCLUSION: We believe that this working definition and the supporting Consensus Statements are a first step to better management of anaphylaxis in the emergency medical setting.
Journal of Emergency Medicine 04/2013; · 1.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: Demonstrate that copeptin level <14 pmol/L allows ruling out AMI when used in combination with cardiac troponin I (cTnI) <99(th) percentile and a non-diagnostic ECG at the time of presentation to the emergency department (ED). BACKGROUND: Copeptin is secreted from the pituitary early in the course of acute myocardial infarction (AMI). METHODS: This was a 16-site study in 1967 chest pain patients presenting to an ED within 6 hours of the onset of chest pain. Baseline demographics and clinical data were collected prospectively. Copeptin and a contemporary sensitive cTnI (99th percentile 40 ng/L; 10% coefficient of variation (CV) 0.03 μg/L) were measured in a core laboratory. Patients were followed for 180 days. The primary outcome was diagnosis of AMI. Final diagnoses were adjudicated by two independent cardiologists blinded to copeptin results. RESULTS: AMI was the final diagnosis in 156 patients (7.9%). A negative copeptin and cTnI at baseline ruled out AMI for 58% of patients, with a NPV of 99.2% (95% CI 98.5-99.6). AMIs not detected by the initial cTnI alone were picked up with copeptin >14 pmol/L in 23/32 patients (72%). NSTEMIs undetected by cTnI at 0h were detected with Copeptin >14 pmol/L in 10/19 patients (53%). Projected average time-to-decision could be reduced by 43% (from 3.0 hours to 1.8 hours) by the early rule out of 58% of patients. Both abnormal copeptin and cTnI were predictors of death at 180 days (p<0.0001 for both, c index 0.784 and 0.800, respectively). Both were independent of age and each other and provided additional predictive value (all p<0.0001). CONCLUSION: Adding copeptin to cTnI allowed safe rule out of AMI with a NPV >99% in patients presenting with suspected ACS. It has the potential to rule out AMI in 58% of patients without serial blood draws. CLINICAL TRIAL: CHOPIN; NCT00952744.
Journal of the American College of Cardiology 04/2013; 62(2):150-160. · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To compare the efficacy of Food and Drug Administration recommended dosing of nicardipine versus labetalol for the management of hypertensive patients with signs and/or symptoms (S/S) suggestive of end-organ damage (EOD). DESIGN: Secondary analysis of the multicentre prospective, randomised CLUE trial. SETTING: 13 academic emergency departments in the USA. PARTICIPANTS: Eligible patients had two systolic blood pressure (SBP) measures ≥180 mm Hg at least 10 min apart, no contraindications to nicardipine or labetalol and predefined S/S suggestive of EOD on arrival. INTERVENTIONS: Medications were administered by continuous infusion (nicardipine) or repeat intravenous bolus (labetalol) for a study period of 30 min or until a specified target SBP ±20 mm Hg was achieved. PRIMARY OUTCOME MEASURE: Percentage of participants achieving a predefined target SBP range (TR) defined as an SBP within ±20 mm Hg as established by the treating physician. RESULTS: Of the 141 eligible patients, 49.6% received nicardipine, 51.7% were women and 81.6% were black. Mean age was 52.2±13.9 years. Median initial SBP did not differ in the nicardipine (210.5 (IQR 197-226) mm Hg) and labetalol (210 (200-226) mm Hg) groups (p=0.862). Nicardipine patients were more likely to have a history of diabetes (41.4% vs 25.7%, p=0.05) but there were no other historical, demographic or laboratory differences between groups. Within 30 min, nicardipine patients more often reached the target SBP range than those receiving labetalol (91.4% vs 76.1%, difference=15.3% (95% CI 3.5% to 27.3%); p=0.01). On multivariable modelling with adjustment for gender and clinical site, nicardipine patients were more likely to be in TR by 30 min than patients receiving labetalol (OR 3.65, 95% CI 1.31 to 10.18, C statistic=0.72). CONCLUSIONS: In the setting of hypertension with suspected EOD, patients treated with nicardipine are more likely to reach prespecified SBP targets within 30 min than patients receiving labetalol. CLINICAL TRIAL REGISTRATION: NCT00765648, clinicaltrials.gov.