Hypertension in the ED comes in two varieties: emergency and asymptomatic (not urgency!). From this position statement: “Hypertensive emergency involves acute target-organ damage and should be treated swiftly, usually with intravenous antihypertensive medications, in a closely monitored setting.”
Conversely, asymptomatic does not require urgent, aggressive management. “Recent observational studies have suggested potential harms associated with treating asymptomatic elevated inpatient BP, which brings current practice into question.”
Without target organ involvement, we do not need to be initiating IV medications or trying to treat the numbers
This article from JAMA is targeted at inpatient management of asymptomatic hypertension, however, it’s a great reminder that “hypertensive urgency” is not an entity. We should be treating the patient and not the numbers. Gradual, out patient lowering of asymptomatic hypertension is the safe and proper way to approach this. Spread the word to your friends in primary care, urgent care, dental, and other office based practices.
The systematic review of presyncope literature found that presyncope should be treated the same as syncope in terms of work up and disposition.
“In conclusion, the prevalence of short-term serious outcomes among ED patients with presyncope ranges from one in four to one in 20, with arrhythmia being the most common serious outcome. Our review indicates that presyncope may carry a similar risk to syncope, and hence, the same level of caution should be exercised for ED presyncope management as that of ED syncope.”
In a cohort of 93,512 ED patients discharged with a diagnosis of hypertension there were 4400 who received a prescription for antihypertensives. The group receiving a prescription had fewer 30 day revisits and adverse events such as MI, CHF, etc.
Previous study’s have found it is safe to prescribe antihypertensives from the ED.
This study is limited by the fact it is not a randomized control trial and there are many variables as to why the select patients received prescriptions
The authors conclude: “Prescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.”
52 yo M with chest pain and shortness of breath, ECG as shown, do you activate cath lab?
The posterior descending artery (PDA) supplies the posterior third of the interventricular septum, including the posterior and inferior walls of the left ventricle. The vessel most commonly originates from either the right coronary artery (right dominant), left circumflex artery (left dominant), or both (codominant).
Posterior MI frequently occurs as an extension of an inferior or lateral infarct. Isolated posterior MI occurs in 3 - 5% of cases (1), and is frequently missed on ECGs.
The posterior myocardium is not directly visualized on a standard 12 lead ECG, but reciprocal changes of STEMI in the anteroseptal leads (V1- V3) are seen (the posterior electrical activity is recorded from the anterior side of the heart)
If in V1- V3 you see
* ST segment depression
* Tall R wave
* Upright T waves
Consider posterior MI as a cause. You need to then obtain an ECG with posterior leads. If there is 0.5 mm elevation in any posterior lead this is diagnostic of posterior MI.
In this study the researchers looked at patients presenting to the emergency department with high suspicion for ACS and explored if Regional Wall Motion Abnormality (RWMA) evaluation by EPs was associated with occlusion myocardial ischemia (OMI).
FOCUS identified RWMA in 87% of patients with coronary angiography proven OMI. With a sensitivity of 94%, specificity 35%, and overall accuracy of 78%.
The authors concluded that using FOCUS can have good utility when a patient is high risk for OMI and has an equivocal ekg. However, if RWMA is not present, physicians should still continue with work up such as cardiac catheterization.
To evaluate RWMA it is easiest to:
For more information check out this ACEPnow article: https://www.acepnow.com/article/detect-cardiac-regional-wall-motion-abnormalities-point-care-echocardiography/?singlepage=1
Opiates Causing Cardiac Toxicity
- Opiates are well known in their ability to cause sedation, euphoria, and respiratory depression, however are classically considered devoid of cardiac properties.
- Methadone a synthetic central-acting μ-opioid receptor agonist has been associated with dose-dependent QTc interval prolongation and torsade de pointes (TdP).
- Utilization of other less known drugs of abuse, specifically loperamide (peripherally acting μ-opioid receptor agonist) has been increasing in popularity.
- A surge in recent case reports has shown a potential causal association of loperamide with prolongation of the QTc interval and subsequent TdP.
- Toxic ingestion of loperamide leading to TdP has been successfully managed with standard TdP therapies (magnesium, isoproterenol, and pacing).
Giant Cell Myocarditis
Giant cell myocarditis (GCM) is an infrequent, but often fatal form of acute myocarditis that has been shown to respond to cyclosporine-based immunosuppressive therapy
Even after heart transplantation GCM recurrence in the donor heart has been cited as high as 20% to 25%
Patients are surviving longer without transplantation because of efficacious medical therapy
A multi-institutional prospective data set revealed several novel findings in GCM:
· Long-term immunosuppression appears capable of lengthening transplantation-free survival ~19 years beyond initial diagnosis
· Cessation and/or reduction of immunosuppression are associated with GCM recurrence
· Patients who developed cyclosporine associate renal failure were able to be switched to a sirolimus-based regimen
Reperfusion Ventricular Fibrillation
Ventricular fibrillation during reperfusion in STEMI is an infrequent, but serious complication.
Among ~4000 with STEMI between 2007-2012, 71 (1.9%) had reperfusion Vfib.
Increased risk for reperfusion Vfib is associated with: history of MI, aspirin and b-blocker use, Vfib before PCI, left main CAD, inferior MI, symptom-to-balloon time <360 minutes, maximal ST-segment elevation in a single lead >300 μV, and sum of ST-segment deviations in all leads >1,500 μV.
The sum of ST-segment deviations in all leads >1500 μV was an independent predictor of reperfusion Vfib.
Ischemic ECG Findings: Significance of the U-wave
The U-wave is a small deflection immediately following the T-wave, commonly with the same polarity as the T-wave and most prominently seen in precordial leads V2–V3.
Prominent U-waves are most often seen with bradycardia and hypokalemia, but can also be secondary to other electrolyte imbalances and medications.
Typically, T- and U-wave polarities are concordant; discordant U-waves have been identified several hours prior to other ECG changes in acute myocardial infarction.
Some studies note that exercise induced U-wave inversion is highly predictive of CAD; negative U -waves in the precordial leads during exercise had a higher specificity (88% vs. 70%) & positive predictive value (77% vs. 61%) for ischemia than ST-depression.
Reinig et al. 2005 showed that negative concordance of T- and U-waves have poor prognosis & is quite specific for ischemia.
· ECG’s were divided into 3 groups:
o Type 1 T-U discordance (negative T waves + positive U waves)
o Type 2 T-U discordance (positive T waves + negative U waves)
o Negative T-U concordance (both T & U waves negative)
* Significantly higher rate of CAD (88% vs. 58%) (P-value <. 0001) in the negative T-U concordance group
Cardiac Sarcoidosis
- Cardiac Sarcoidosis (CS) is reported to involve ~2-5% of patients with systemic sarcoidosis. An increasing proportion of patients are presenting with isolated CS.
- Isolated CS is associated with a higher female predominance; severe LV involvement, heart failure, and poor prognosis.
- Manifestations range from symptomatic conduction disturbances, dysrhythmias, progressive heart failure, and silent myocardial granulomas - leading to sudden cardiac death.
- CS is a serious condition with a quoted 5-year survival ~60-75%.
- Corticosteroid therapy is considered cornerstone in management, but evidence is largely observational and no randomized trials have been performed to date.
The Heart Is Just a Muscle
- Heart failure and peripheral myopathies share similar symptoms such as exertional fatigue, weakness, and dyspnea.
- The role of endomyocardial biopsy (EMB) to aid in the diagnosis of new-onset heart failure is controversial and major society guidelines recommend against this procedure in the routine evaluation of patients with heat failure.
- Nevertheless when symptoms of heart failure persist despite conventional imaging modalities and treatment one must consider uncommon conditions, such as mitochondrial disorders.
- Mitochondrial disorders are characterized as clinical syndromes and patients can present with any one of the following: ophthalmoplegia, proximal muscle weakness, isolated myopathy with exercise intolerance and myalgia, severe myopathy of infancy or childhood, or multisystem involvement with myopathy.
- Myocardial tissue is highly dependent on mitochondria for energy production and is therefore susceptible to defects in mitochondrial function. Cardiac manifestations of these syndromes include both arrhythmias and cardiomyopathy.
Acute Pericarditis
- Pericarditis has numerous etiologies; in developed countries 80-90% of cases are idiopathic/viral & 10-20% of cases are most commonly post-cardiac injury syndromes, connective-tissue diseases, or cancer.
- Diagnosis requires at least two of the following symptoms or signs: chest pain, pericardial friction rub, typical electrocardiographic changes, and pericardial effusion.
- Since pleuritic chest pain has many possible causes, pericarditis should be diagnosed with caution in the absence of other clinical criteria, additionally a friction rub & ECG findings may be transient making the diagnosis even more challenging.
- Data from a recent RCT indicated that pericardial effusions are present in ~2/3 of patients; the vast majority are small and of no concern, nonetheless an echocardiogram is routinely indicated and if present should be carefully followed to assess for tamponade.
- Treatment for idiopathic/viral cases of pericarditis consistents of NSAIDs & colchicine.
Afib Clinical Decision Aid: AFFORD
- Atrial fibrillation (AF) affects ~34 million people worldwide; the hospital admission rates vary with frequencies of 81%, 62%, and 24% in the US, Australia, and Canada respectively.
- Lack of a reproducible and accurate risk stratification/decision aid likely contributes to variability in ED disposition.
- AFFORD (Atrial fibrillation and flutter outcome risk determination) was the 1st clinical decision aid (contains 17 variables) to predict 30-day adverse events in a prospective ED patient cohort with acute symptomatic AF.
- Vanderbilt University Medical Center's ED (2010-2013) derived and internal validated an ED based clinical decision aid for prediction of MACE within 30 days utilizing the AFFORD decision aid in hemodynamically stable patients whose AF reverted to sinus rhythm, either spontaneously or after cardioversion (pharmacologic or electrical), and those who are adequately rate controlled and candidates for outpatient management.
- Incorporating AFFORD with a shared decision model into ED practice may help identify patients at low risk and potentially reduce rate of hospitalizations.
Safety Risk? Digoxin in Atrial Fibrillation
- Digoxin is commonly utilize for atrial fibrillation/flutter with rapid ventricular response, though beta blockers and/or calcium channel blockers are a better 1st line therapy given digoxin’s narrow therapeutic index and lack of mortality benefit.
- Digoxin in the acute setting is often favored given its ability to reduce the heart rate while maintaining or slightly augmenting blood pressure.
- 2014 AHA/ACC guidelines recommend digoxin, specifically for rate control in patients with heart failure and/or reduced ejection fraction.
- There have been 2 post hoc studies from the AFFIRM trial which showed conflicting results w/regards to digoxin and risk of mortality.
1. Increased risk of mortality associated w/digoxin (on-treatment analytic strategy)
2. No association w/mortality (intent-to-treat analytic strategy)
- A recent retrospective cohort examination of newly diagnosed afib patients without heart failure & no prior use of digoxin; digoxin was independently associated with a 71% higher risk of death & a 63% higher risk of hospitalization.
- Consistent and substantial increase in mortality and hospitalization risk was seen using both on-treatment and intent-to-treat analytic methods.
- Given other available rate control options, digoxin should be used with caution.
The Unforgotten: ECG Utilization to Differentiate Athletic Heart vs. Brugada
- Highly trained athletes develop ECG changes as a physiologic consequence of increased vagal tone; The ECG manifestations of early repolarization (ER) can range from simple J–point elevation to anterior (V1 to V3) "domed" ST-segment elevation and negative T wave.
- The former raises problems of differential some forms of ER with the “ coved-type” pattern seen in Brugada Syndrome (BS).
- A recent study compared the ECG tracings of 61 athletes w/a “domed” ST-segment elevation & negative T wave and 92 age/sex-matched BS patients w/a “ coved-type” pattern to identify an ECG criteria for distinguishing benign athletic changes seen in ER from BS.
- ECG analysis focused on ST-segment elevation at J-point (STJ ) and at 80 milliseconds after J-point (ST80 ).
- Athletes had a lower maximum amplitude of STJ (p < 0.001) & lower STJ /ST80 (p < 0.001)
- All patients (100%) with BS showed a downsloping ST-segment configuration (STJ/ST80 > 1) versus only 2 (3%) athletes (p < 0.001)
- An upsloping ST-segment configuration (STJ /ST80 < 1) showed a sensitivity of 97%, a specificity of 100%, and a diagnostic accuracy of 98.7% for the diagnosis of ER.
A: ER
B: Brugada
Posterior Myocardial Infarctions (PMI)
- Posterior myocardial infarctions (PMI) are different than typical ST-elevation MI; the ECG findings include: septal & anterior ST-segment depression, dominant tall/broad R waves, and upright T waves.
- In a study among 117,739 subjects with STEMI, 824 with PMI were more likely to present with cardiac arrest, cardiogenic shock, and congestive heart failure.
- The median time from arrival ECG to revascularization with PCI was longer among subjects with PMI.
- The median time from arrival ECG to systemic thrombolysis was also longer among subjects with a PMI.
- Increased awareness and recognition of PMI is needed to improve reperfusion times among this subpopulation with STEMI.
Left Ventricular Hypertrophy & Arrhythmias: Any Association?
Associations between left ventricular hypertrophy (LVH) and both supraventricular (SVT)/ventricular arrhythmias (VT/VF) have previously been reported.
A recent review & meta-analysis of 10 studies (27,141 patients) revealed the following:
- Incidence of SVT was 11% with LVH compared to 1% without (p <0.001)
- LVH patients had 3.4-fold greater odds of developing SVT
- Incidence of VT/VF was 5.5% with LVH compared to 1.2% without (p <0.001)
- LVH patients has 2.8 greater odds of developing VT/VF
The reason for increased arrhythmogenicity in LVH is not clearly understood.
A consistently observed abnormality in LVH is non-uniform propagation of the action potential throughout the myocardium, which sets the stage for arrhythmias based on early or delayed afterdepolarizations.
Given the heterogeneity in this meta-analysis further research between LVH & sustained arrhythmias is needed to infer true causality.
APACHE-HF Scoring System
The Acute Physiology and Chronic Health Evaluation (APACHE) scoring system was established in the 1980's to predict critically ill patient prognosis (APACHE II, III, and IV have been published in last two decades).
The APACHE II scoring system involves combining 3 separate scores (acute physiology score, chronic health score, and age), which can be cumbersome to apply & thus is not often utilized in the emergency department (modified APACHE II doesn't include chronic health score & is less taxing).
No unique scoring system for acute heart failure (AHF) has been analyzed until present; the APACHE-HF score includes 8 criteria: mean arterial pressure (MAP), pulse, sodium, potassium, hematocrit, creatinine, age, and glasgow coma score (GCS).
AHF in-hospital mortality data was analyzed and compared using APACHE II, modified APACHE II, and APACHE- HF scores and the predictive value of the APACHE-HF score was found to be optimal when compared to the others.
