Article Reviews - CRIT CLOUD

Acute myocardial infarction - It's pain radiating to the right arm we have to worry about!

15/3/2019

It was only back in in 1987 when William Heberdeen (not to confound with William Heberdeen, a London doctor who described the Heberdeen nodes back in the 18th century) published the first description of ischemic chest pain. It was the birth of the classical image of strangling chest pain that occasionally radiates to the left arm, associated with exertion and relieved by rest.

A recent publication in the BMJ shows, that positive troponin levels are found frequently in patients with non-cardiac problems. This finding underlines the importance of good history taking, including the assessment of chest pain (CP) characteristics.

Circulation. 2018;138:e618–e651. (Click image for link to article)

The TRAPID-AMI Study

McCord J et al. have taken a closer look at chest pain and associated symptoms and their association with the diagnosis of acute myocardial infarction. They also analysed these symptoms in relation to the size of the AMI.

They performed an

international, multicenter diagnostic study

in which they evaluated

1282 patients admitted for possible AMI to emergency departments in Europe, the US and Australia

The outcome was

the correlation of symptoms with the diagnosis of AMI and its relation to myocardial infarction size

They found that

1. only 4 symptoms were independently predictive of AMI

- Radiation to the right arm/ shoulder (OR 3.0, CI 1.8-5.0)
- Chest pressure (OR 2.5, CI 1.3-4.6)
- CP worsened by physical activity (OR 1.7, CI 1.2-2.5)
- Radiation to left arm/ shoulder (OR 1.7, CI 1.1-2.4)

2. Patients with more than 1 of the 4 symptoms were more likely to have AMI
- For patients who had all 4 symptoms, 55% had a diagnosis of AMI

3. Patients with larger AMI's were more likely to have
- pulling CP
- pain in the right upper chest (right supramammillary area)
- and right arm/shoulder radiation

- It's time to get rid of the classical image of CP radiating only into the left arm. While this might still be the predominant complaint at presentation, it's the right sided shoulder/ arm pain we should keep a close eye on!

- Chest pain radiating to the right shoulder/ arm is more predicitive of myocardial infarction than left sided chest pain

- And remember: a positive Troponin alone does not fullfill the diagnostic criteria of AMI!

Crit Pathw Cardiol. 2019 Mar;18(1):10-15.

Identify a Pacer by Chest X-Ray

29/10/2017

Clinicians are confronted every day with a growing number pacemakers (PMs), implantable cardioverter-defibrillators (ICDs) and implantable loop recorders (ILRs). Collectively these devices are sub summarised as cardiac rhythm management devices (CRMDs). Identification of these devices is simple as long a the patient can present an ID card or some other form of identification. This can become challenging especially in emergencies where such information might not be accessible, and interrogation of the pacemaker becomes a problem.
Using the wrong manufacturer-specific device programmer causes a delay in diagnostic and treatment and can be relevant in these situations.

Techniques to identify a CRMD are following:

- Patient's ID card

- Medical records

- Manufacturers' patient registries (All CRMD manufacturers keep their own in-house registry of patients implanted with their devices and provide 24-hour telephone technical support

- Device specific radiopaque alphanumeric codes (ANC)

All these identification techniques have their problems in clinical practice, and so far no other method or algorithm was available to help out in such a dilemma. Sony Jacob et al. have therefore developed and validated the so-called

Cardiac Rhythm Device Identification Algorithm using X-rays (CaRDIA-X, see below)

The study participants using this algorithm showed an overall accuracy of 96.9%. This study was published in 2011 but only now caught our attention.

We have tried this algorithm on a few X-rays ourselves and came to the conclusion:

Using the chart is a little challenge itself, but very helpful in most cases! Certainly worth keeping in mind!

Jacob S et al. Heart Rhythm. 2011 Jun;8(6):915-22.

OUT NOW: New and Updated ILCOR 2015 Treatment Recommendations on Cardiopulmonary Resuscitation

23/10/2015

Since the year 2000 the International Liaison Committee on Resuscitation (ILCOR) continues to evaluate all evidence and updates their recommendations in 5-year cycles. The most recent ILCOR 2015 International Consensus Conference was held in Dallas last February and the new treatment recommendation are out now.

Resuscitation remains one of the most challenging situations in health care. Providing basic and advanced cardiac life support gives you the opportunity to virtually safe a patients life but in a very limited period of time. It is an enormous challenge to consider all emerging evidence and pack this into simple and useful guidelines.

It is imperative to for any health care provider to get familiar with the updated guidelines and major changes. Below you can find all relevant links to get the reading going.

The team of BoringEM.org in Canada have provided some excellent infographics to visualise all important changes in the new treatment guidelines since 2010. You should also note that the Canadian Heart & Stroke Association and the American Heart Association have just published the 'HIGHLIGHTS of the 2015 American Heart Association Guidelines Update for CPR and ECC', an excellent summary of the new recommendations and changes. So if you can't find the time to read all of the publication in 'Circulation', this will certainly provide all information you need to know.

Summary of the Canadian Heart & Stroke Association and the American Heart Association: HIGHLIGHTS of the 2015 American Heart Association Guidelines Update for CPR and ECC

The original publication in Circulation, October 20, 2015, Volume 132, Issue 16 suppl 1
OPEN ACCESS

The Most Important Changes (Click to Enlarge)

The Updated Algorithms (Click to Enlarge)

ERC and ESICM 2015 Guidelines for Post-Resuscitation Care

Based on the the 2015 ILCOR treatment recommendations the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have produced these post-resuscitation care guidelines on October the 13th. Recent changes here are the greater emphasis for urgent PCI when indicated, target temperature management at 36°C, prognostic evaluation using a multimodal strategy and an increased emphasis on rehabilitation after survival.

Nolan JP, Resuscitation, October 2015, Pages 202 - 222

Oxygen in Acute Myocardial Infarction: Challenging the Next Medical Automatism

30/7/2015

A number of things we do for patients in the ICU we simply do... because it has been always done. Maybe because it seems to make sense or because we were simply taught to do so. One of these treatments is the application of oxygen to patients suffering of myocardial infarction. But in fact the impact of this measure is not that well established and we know that high concentrations of oxygen can actually be harmful. Some previous studies suggest possible increase in myocardial injury.

Stub et al. therefore performed a multicenter, prospective, randomised controlled trial comparing oxygen (8 L/min) with no supplemental oxygen in patients with STEMI diagnosed on paramedic 12-lead electrocardiogram. They finally included 441 patients into their study.

Their primary endpoint was evaluation of infarction size assessed by the cardiac enzymes troponin (cTnI) and creatine kinase (CK). While troponin levels did not differ there was a significant difference in the mean peak CK levels, being higher in the group with oxygen applied. By looking at the secondary endpoints they also found an increase in the rate of recurrent myocardial infarctions and in the frequency of cardiac arrhythmia among the oxygen group. Finally at 6-months the oxygen group had an increase in myocardial infarct size on cardiac MRI.

They conclude that patients with myocardial infarction but without hypoxemia may actually not benefit of supplemental oxygen therapy.

Time to question our automatisms when treating patients.

Stub et al. Circulation. 2015 Jun 16;131(24):2143-50.

Another Hole in the Ballon (-Pump)!

7/5/2015

In the late 1960's the technology of counter-pulsation by using an intra-aortic balloon pump (IABP) was introduced into clinical work. Based on the principle of diastolic inflation and systolic deflation, IABP counter-pulsation improves diastolic coronary artery blood flow and decreases left ventricular afterload. Up to the year 2009, 2012 respectively, the usage of an IABP in patients with ST-segment elevation myocardial infarction and cardiogenic shock was considered a class IC recommendation (reminder: levels of evidence).

Since then a couple of well conducted, larger trials have failed to show a positive impact of IABP especially on mortality. In regards of the most recent meta-analysis in JAMA we provide a short overview of the most important publications. It's interesting to see that the balloons undermining started with a meta-analysis and for the the time being ends with one.

Stitch no.1

The first notable hole in the ballon was caused by Sjauw et al.'s systematic review and meta-analysis in the European Heart Journal in 2009. Their pooled randomized data consisting of two separate meta-analyses did not support the use of an IABP in patients with high risk STEMI. They concluded that there is insufficient evidence endorsing the current guideline recommendation for the use of IABP therapy in the setting of STEMI complicated by cardiogenic shock.

This publication was one of the main reasons for the expert panel of the European Society of Cardiology to change the recommendation (ESC Guidelines 2012) to use an IABP in patients with STEMI from IC to IIB.

Stitch 2 and 3

In the same year 2012 Thiele et al. published their first IABP-SHOCK II results in the NEJM. Their
randomized, prospective, open-label, multicenter trial showed no reduction in the 30-day mortality compared to the best available medical therapy alone in patients with myocardial infarction-induced cardiogenic shock and planned early revascularization (PCI or CABG).

One year later the IABP-SHOCK II investigators published their final 12-months results in The Lancet. They came to the final conclusion that in patients undergoing early revascularization for myocardial infarction with cardiogenic shock, IABP did not reduce 12-month all-cause mortality.

Stitch no. 4

In 2013 Ranucci at al. presented the results of their single-center prospective randomized controlled trial looking at the usage of a preoperative IABP in high-risk patients undergoing surgical coronary revascularization. By looking at a total of 110 patients with an ejection fraction below 35% and no hemodynamic instability there was no improvement in outcome when inserting an IABP preoperatively.

Preliminary Final Stitch

So finally Ahmad and his team decided to assess IABP efficacy in acute myocardial infarction by performing an updated meta-analysis. Main outcome was 30-day mortality. They included 12 eligible RCTs randomizing 2123 patients and found no improvement in mortality among patients with acute myocardial infarction... regardless of whether patients had cardiogenic shock or not!
A look at another 15 eligible observational studies with a total of 15 530 patients showed basically conflicting results which was explained by the differences between studies in the balance of risk factors between IABP and non-IABP groups.

It seems that the IABP fails to show its assumed efficacy in patients with myocardial infarction and cardiogenic shock, especially when early revascularization (PCI or CABG) is available.

As a general consideration and also when no early revascularisation is available the use of another left-ventricular assist device like the Impella pump might prove to be a good and easy to use alternative (see blow).

Sjauw KD et al. Eur Heart J 30: 459-468

ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 33: 2569-2619 OPEN ACCESS

Thiele et al. N Engl J Med 2012; 367:1287-1296 OPEN ACCESS

Thiele et al. The Lancet, Volume 382, Issue 9905, Pages 1638 – 1645

Crit Care Med. 2013 Nov;41(11):2476-83

JAMA Intern Med. Published online March 30, 2015

Short film on the principle of the Impella pump 2.5. Bare in mind that this device can actually be easily inserted in the environment of ICU and positioned by using transthoracic echo TTE.

New Guidelines for the Management of Atrial Fibrillation

13/3/2015

In December 2014 the AHA, ACC and HRA have released a new bunch of guidelines on the management of patients with atrial fibrillation (AFib). The paper itself is worth reading as it looks into the basic understanding of this condition, its clinical evaluation and finally the treatment options.

As these guidelines are open access it can be considered mandatory Free Open Access Meducation FOAMed. Below is a summary of the Recommendations according to specific patient groups.

It's interesting to notice that digoxin still plays a role in patients with heart failure, especially when looking at the findings of Turakhia et al. in JACC, Aug 19 2014.

J Am Coll Cardiol. 2014;64(21):2246-2280 OPEN ACCESS

BIJC post on dixogin in critical care

Digoxin Fading Away for Treatment of Atrial Fibrillation

13/8/2014

After a pause and thanks to Kuno's attentiveness following article found it's way to our website: Although not being very popular in the world of intensive care Digoxin remained a component of our armament and was continued to be used for patients with atrial fibrillation.
After its long era in medicine findings of the TREAT-AF are now about to bring this to a possible end.
Turakhia et al. looked at over 122'000 patients with newly diagnosed, non valvular AF in the U.S. between 2004 to 2008. They specifically looked at the use of Digoxin and the occurrence of death. Residual confounding was assessed by sensitivity analysis. They found a cumulative higher mortality rate for patients treated with Digoxin, which persisted after multivariate adjustment, propensity matching and adjustment for drug adherence.

The findings of this study are impressive and even led Harlan Krumholz, editor-in-chief of NEJM Journal Watch Cardiology, to the statement: 'It's time to pause on Digoxin until studies can assure that it's providing a net benefit to these patients'.

Turakhia et al. JACC, Aug 19 2014; Volume 64, Issue 7

NEJM Journal Watch Cardiology

Early Systematic Coronary Angiography in All Out-Of-Hospital Cardiac Arrests Seems Reasonable

9/6/2014

The most recent guidelines of the European Resuscitation Council and the American Heart Association recommend that resuscitated patients of presumed cardiac cause should undergo immediate coronary angiography with subsequent PCI if indicated, regardless of clinical symptoms and/or ECG criteria. However, this approach is discussed controversially as we don't know if there is any benefit on performing an angiography in every out-of-hospital cardiac arrest (OHCA). Additionally such an approach might be associated with quite some logistical and organisational problems for certain institutions.

In this noteworthy and open access review article Geri et al. discuss current literature and state that there are no randomised studies looking at acute coronary angiography in OHCA patients. A large number of observational studies though supports feasibility and a possible survival benefit of an early invasive approach.

They conclude that even in the absence of large randomised studies, it is probable that an early coronary revascularization is associated with a significant clinical benefit in OHCA survivors.

Providing the patient had no other obvious reason for OHCA (sepsis, haemorrhage, metabolic disorder etc.) current literature strongly encourages performing a systematic coronary angiography in all OHCA patients.

Geri G et al., Current Opinion in Critical Care, June 2014, Vol 20, Issue 3 (Open Access)

Intermediate Risk PE's Need Thrombolysis, but this Is Dangerous: Will This Trial Open the Door for 'Safe Dose Thrombolysis'

11/4/2014

On the 21st of February this year we mentioned a paper by Sharifi et al. who introduced a new concept of 'Safe Dose Thrombolysis'. Background is the fact that for most patients, e.g. intermediate risk pulmonary embolism (PE), thrombolysis is not recommended due to the risk of bleeding. The question though remained wether intermediate risk patients actually also would benefit of thrombolysis in terms of outcome.

In the recent NEJM now a trial is presented where the investigators focused on exactly this so called 'intermediate risk' group of patients. They randomized 1005 patients with PE who had right ventricular dysfunction on echocardiography or computed tomography, as well as myocardial injury as indicated by a positive test for cardiac troponin I or troponin T. The one group received tenecteplase and heparin, the other only heparin.

Result: Thrombolysis prevented hemodynamic decompensation and death... but at the same time increased the risk for major hemorrhage and stroke. What a dilemma!

That's where I feel 'Safe Dose Thrombolysis' might be interesting to look at. Now there's a good topic for your next publication in the NEJM, go for it!
(and please don't forget to mention us for the great idea ; )

Meyer G et al. N Engl J Med 2014; 370:1402-1411

Sharifi M et al. Clin Cardiol. 2014 Feb;37(2):78-82

Acute Myocardial Infarction, COPD and Beta Blockers... Go For It!

10/4/2014

Most of us are aware of the medical leaflet warning that beta blockers in bronchospastic disease should be avoided or at least be given with great caution due to the risk of increased airway resistance. An interesting question therefore is, whether beta blockers prescribed in COPD patients with acute myocardial infarction (AMI) also benefit of their effect and if this also affects survival.

Quint et al. have looked into this topic by performing a retrospective study including 1063 COPD patients, who experienced their first AMI. 55.1% of these patients were never prescribed a beta blocker throughout the study period, 23% were on beta blockers before and 21.9% were prescribed a beta blocker during their hospital admission for AMI.

Patients started on beta blocker during their hospital admission showed substantial survival benefits compared to patients who were not prescribed any beta blockers. Patients taking beta blockers before their first myocardial infarction also showed a substantial survival benefit!

Taking into the account these results and the increasing evidence that beta blocker are actually safe in COPD patients suggests that beta blockers should be used more widely in patients at risk for AMI.

At least we should not be too worried to prescribe them.

Quint J K et al. BMJ 2013;347:f6650

Dransfield M T et al. Torax 2008;63:301-305

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