cardio literature update

8/3/2019 Cardio Literature Update

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Amal Mattu, MD, FAAEM, FACEP

Professor and Residency Director

Department of Emergency Medicine

University of Maryland School of Medicine

Baltimore, Maryland

EmergencyCardiology Update

The Articles YouveGot to Know!!


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For This Lecture

45 minutes 2 topicsCardiac arrest and pericarditis vs. AMI

Recent cases Handout very comprehensive See handout for

New LBBB

Syncope in the elderly


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Amal Mattu, MD

No financial relationships with drug or

device-manufacturing companies


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Cardiac Arrest

What is a successful resuscitation?Return of spontaneous circulation (ROSC)?Survival to hospital admission?Survival to hospital discharge?Neurologic recovery? How much?


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Cardiac Arrest

Myth: High dose epinephrine (HDE) isassociated with a higher rate of

successful resuscitation.


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Cardiac Arrest

Reality:

1. HDE may beassociated with an increase

in ROSC and survival to hospital admission.

2. HDE is notassociated with an increase in

hospital dischargeor neurologic recovery.

3. HDE may be associated with a decreasein

neurologic recovery.


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Cardiac Arrest

2000: Amiodarone is more effective thanEPI in cases of pulseless VT/VF.


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Cardiac Arrest

Reality: 2005 AHA Guidelines

Antiarrhythmics: There is no evidence thatany antiarrhythmic drug given routinelyduring human cardiac arrest increasessurvival to hospital discharge. (Hazinski,Circulation, 2005)


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Cardiac Arrest

2000: Vasopressin may be preferable toEPI for patients with cardiac arrest.


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Cardiac Arrest

Reality: 2005 AHA Guidelines

Vasopressors: To date no placebo-controlled trials have shown thatadministration of any vasopressor agent atany stage during management of pulselessVT, VF, PEA, or asystole increases the rate ofneurologically intact survival to hospital

discharge. (Hazinski, Circulation, 2005)


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Cardiac Arrest:

Summary of ChangesMajor Changes in the 2005 AHA Guidelines

for CPR and ECC: Reaching the TippingPoint for Change

(Hazinski MF, Circulation 2005)

Summary (all to improve compressions)Avoid hyperventilation (max. 12/min) 100 compressions/minAvoid stacked shocks and escalating dosages of Joules 2 minutes of compressions before first shock 2 minutes of compressions after eachshock before

pulse check

De-emphasis on ALL medications


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So what works??


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2010


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Case 1

45 yo many presents to the ED withatypical chest pain, wife present

In room for 20 minutes, then Diaphoretic Clutches chest Unresponsive Monitor...


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Case 1


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Case 1

Patient gets standard 2005-9 care:BVM (12/min), good compressionsRapid defibrillation ASAP

Maximum joulesOne timeResume BVM and compressions

Rapid intubation, ventilation 12/min+ Drugs vasopressor, antiarrhythmicDefibrillation again in 2 minutesEtc.


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Cardiac Arrest

What do we now need to reconsider?BVM (12/min), good compressionsRapid defibrillation ASAP

Maximum joulesOne timeResume BVM and compressions

Rapid intubation, ventilation 12/min+ Drugs vasopressor, antiarrhythmicDefibrillation again in 2 minutesEtc.


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A-B-C?


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Cardiac Arrest

What recent literature is demonstrating?Positive pressure ventilation (MTM, bagging,

ETI) have adverse consequencesCauses reduction in compression ratesDecreased CO and cerebral perfusion

Probably not necessary early after suddencardiac arrest (central oxygen sats. okay)


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ABC CCR?


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Cardiac Arrest

Recent Advances in Cardiopulmonary

Resuscitation: CardiocerebralResuscitation(Ewy, et al. J Am Coll Cardiol 2009)

Improved Patient Survival Using a Modified

Resuscitation Protocol for Out-of-HospitalCardiac Arrest

(Garza, et al. Circulation 2009)


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Cardiac Arrest

Cardiocerebral Resuscitation

Concept first described in 2002Continuous chest compressions

without ventilation

Delayed PPV and intubationEarly EPI (to promote circulation)


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Cardiac Arrest


(Kellum, et al. Ann Emerg Med 2008) Studied CCR for prehospital witnessedarrests with an initially shockable rhythm

CCR initiated by EMS personnel Non-rebreather mask only, until ROSC or5 cycles of compressions (10 min!) +

shocks Early EPI


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Cardiac Arrest


(Kellum, et al. Ann Emerg Med 2008) Overall survival increased from 20% 47%

Survival neurologically intact increasedfrom 15% 39%


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Cardiac Arrest


(Garza, et al. Circulation 2009) Compared 1097 pts. receiving oldprotocol vs. 339 pts. receiving CCR

Pre-hospital VF arrest in adults Presumed cardiac cause (e.g. notdrowning, OD, etc.)Gentle ventilations (50:2), NRB mask No intubation for 3 cycles (6 minutes)


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Cardiac Arrest


(Garza, et al. Circulation 2009) For patients with witnessed arrestSurvival to discharge 22% 44%

88% of these CCR survivors dischargedwith good neurological outcome


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Case 1

Patient gets ROSC but still unconscious (Pre- or) Post-arrest ECG


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Case 1

(Pre- or) Post-arrest ECG


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Case 1

Do you activate the cath lab?? At 1am?


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Cardiac Arrest

Survival and Neurologic Recovery in

Patients With STEMI Resuscitated FromCardiac Arrest(Hosmane, et al. J Am Coll Cardiol 2009)

Emergency PCI in Patients With STEMI

Complicated by OOHCA(Lettieri, et al. Am Heart J 2009)


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Cardiac Arrest



98 pts underwent PCI after resuscitation64% survived92% of these had full neurological recovery


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Cardiac Arrest



What about unconscious post-resus?59 pts44% survival88% of these had full neurologic recovery


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Cardiac Arrest

Emergency PCI in Patients With STEMI

Complicated by OOHCA(Lettieri, et al. Am Heart J 2009) OOHCA patients with STEMI going for

PCI (and surviving) had similar 6-month

outcome to non-CA patients 87% favorable neuro status at 1 year


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Cardiac Arrest

Regional Systems of Care for OOHCA: A

Policy Statement from the AHA(Circulation Feb 9, 2010) If OOHCA associated with STEMI, field

providers should bypass nearest

hospitalsand go directly to a cardiacresus receiving hospital so patients can

receive angiography within 90 minutes


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Case 1what if

ECGs show non-STEMIactivate cath?


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Cardiac Arrest

Coronary Angiography Predicts ImprovedOutcome Following CA

(Reynolds, et al. J Int Care Med 2009) Improved survival and outcome

associated with cath, regardlessofPresenting rhythmPresence of STEMI or new LBBBNeurologic status

Cath independently associated withgood outcome


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Cardiac Arrest

Regional Systems of Care for OOHCA: A

Policy Statement from the AHA(Circulation Feb 9, 2010)Absence of STE on 12-lead ECGis not

strongly predictive of the absence of

coronary occlusion on acuteangiography.

Increasing support for rapid PCIregardless of ECG after ROSC


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Cardiac Arrest

Recent Advances in CPR: CCR

(Ewy, et al. J Am Coll Cardiol 2009) Urgent cardiac catheterizationThe most influential factor in survivalRegardless of whether or not STEMI!


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Cardiac Arrest

Historical advances in Tx of cardiac arrest 1980s-1990s rapid defibrillation Early 2000s therapeutic hypothermia Late 2000s CCR, rapid PCI


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Case 1

Plan emergent PCI Patient still unconscious Before the cath, should we.?


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Case 1

Mild therapeutic hypothermia in patientsafter OOHCA due to STEMI undergoing

immediate PCI(Wolfrum, et al. Crit Care Med 2008)

Small study showed trend toLower 6-month mortalityImproved neurologic statusNo change in door-to-balloon times


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Cardiac Arrest

SummaryCCR > ABC and CPR

Airway in most CAs no rush!Immediate PCI for STEMIs regardless of

neuro statusIncreasing support for NSTEMI

Increasing support for therapeutichypothermia during PCI


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Case 2

53yo man presents with chest pressure,dyspnea, palpitationsCRFs are smoking and hypertensionECG


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Case 2

53yo man presents with chest pressure,dyspnea, palpitationsCRFs are smoking and hypertension


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Case 2

53yo man presents with chest pressure,dyspnea, palpitations

Cardiol Dx STEMIcath lab activation


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Case 2

Cath clean coronaries Developed hemorrhagic pericardial

effusion Diagnosis acute pericarditisWhy was the ECG mis-read in the ED?

By the emergency physiciansBy the cardiologists


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ECGs and Pericarditis

Differentiating STEMI and NonischemicCauses of STE by Analyzing the

Presenting ECG(Jayroe, et al. Am J Cardiol, 2009)

116 ECGs showing STE (only 8 STEMIs) 15 experienced cardiologists Patients had chest painAsked Does this patient need PCI?


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Differentiating STEMI and NonischemicCauses of STE by Analyzing the

Presenting ECG(Jayroe, et al. Am J Cardiol, 2009)

Senst. for STEMI 50-100% (avg. 75%) Spec. for STEMI 71-97% (avg. 85%) No difference between US vs. European

cardiologists


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Takehome point: Dont rely on your cardiologists to be

gold standards for ECG interpretation!You need to be THE expert at ECGs!


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Frequency and predictors of urgentcoronary angiography in patient with

pericarditis(Salisbury, et al. Mayo Clin Proc 2009)

Acute Pericarditis: Appendicitis of the

Heart? (editorial)(Bainey, et al. Mayo Clin Proc 2009)


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Coronary angio for pericarditis 17% (out of 238) of patients with final

diagnosis of pericarditis sent for PCI c/w prior study (Larson, JAMA 2007)

15-20% of patients with presumed STEMIsent for PCI that had clean cath wereeventually diagnosed as having pericarditis

Why is this distinction so difficult?


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Coronary angio for pericarditis Positional/pleuritic pain neither sensitive

nor specific 12% had pain c/w typical angina Recent viral illness in < 50% Pericardial effusions in < 40% Friction rub in < 15% TN levels elevated in 16%


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Coronary angio for pericarditis Takeaway point for AP vs. STEMI

History provides minimal helpPE provides minimal helpAnd that leaves


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1. Factors that rule-in STEMISTD except in V1 or aVR

(STD in V1 or aVR is allowed in AP)STE in III > IIHorizontal or convex upwards STEQ-waves that you know are new

2. Factors that suggest APFriction rubPR depression in multiple leads

(Only reliably seen in viral AP, transient)


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When in doubt, getserial ECGs!


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STEMI or AP?


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STEMI or AP?


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STEMI or AP?


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STEMI or AP?


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STEMI or AP?


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STEMI or AP?


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STEMI or AP?


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STEMI or AP?


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STEMI or AP?


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STEMI or AP?


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STEMI or AP?


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STEMI or AP?


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STEMI or AP?


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Cardiac Arrest

SummaryCCR > ABC and CPR

Airway in most CAs no rush!Immediate PCI for STEMIs regardless of

neuro statusIncreasing support for NSTEMI

Increasing support for therapeutichypothermia during PCI


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Factors that rule-in STEMISTD except in V1 or aVR

(STE in V1 or aVR allowed in AP)STE in III > IIHorizontal or convex upwards STEQ-waves that you know are new

Factors that suggest APFriction rubPR depression in multiple leads

Only reliably seen in viral AP, transient


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Thanks!

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