Tag Archives: journal club
Journal Club – IV TNK compared with tPA for Acute Ischemic Stroke in Canada
Journal Club – Diagnostic Accuracy of ECG for Acute Coronary Occlusion resulting in MI
Presenter: Dr. Nick Byers (iFMEM R2)
Host: Dr. Colin Rouse
Article:
Research question/PICOD
- Question:
- Does shifting from a STEMI/NSTEMI paradigm to a new approach (ACO-MI/ non-ACO-MI) result in better identification of the patients who need acute reperfusion therapy?
- Population:
- Adult ED patients with ACS Symptoms
- Intervention/Comparison:
- STEMI/NSTEMI vs ACOMI/NACOMI
- Outcome:
- Composite ACO defined as one of:
- A) Total occlusion or presence of culprit lesion on angiography with a peak troponin I level equal to or greater than 1.0 ng/mL plus an at least 20% rise within 24 h
- B) A highly elevated peak troponin (greater than 5.0 ng/mL), which was shown to be correlated with ACO
- C) Cardiac arrest before any troponin rise has been documented with supporting clinical evidence of possible ACO
- All cause in hospital mortality
- All cause long term mortality
- Composite ACO defined as one of:
- Secondary Outcomes:
- Time from ECG to coronary angioplasty or CABG
- The sensitivity and specificity of current criteria in diagnosing ACO
- The sensitivity and specificity of ECG without ST-segment elevation to diagnose ACO (accuracy of ECG interpretation of acute coronary occlusion without STEMI criteria)
- The specificity of ECG with STEMI criteria (correct ECG interpretation of false positive STEMI criteria)
- The sensitivity of ECG with STEMI criteria (correct ECG interpretation of false negative STEMI criteria)
- The outcome according to ECG subclassifications (outcomes of the patients who are labeled as STEMI and the patients who are labeled as having NSTEMI but have acute coronary occlusion)
- Design:
- Single center, retrospective case-control study in Turkey
Results
Authors conclusions
“We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI”
Discussion at Journal Club
Strengths
- 3000 patients included, 1000 per arm
- Reviewers were blinded, disagreements were resolved by a 3rd independent reviewer
- EKGs were reviewed again 3 months later to decrease inter-observer variability
- Consecutive patients with an initial diagnosis of MI (i.e. not a convenience sample)
- All patients received guideline-recommended medical treatment
- There were documented criteria of ECG findings to classify the ECGs
Weakness
- This was a retrospective study and at a single centre.
- When troponins were taken was not controlled for/accounted for in any way
- Control group age, medical comorbidities, and cardiac risk factors were much less
- Their results suggest 17% of patients in N-ACOMI (N-STEMI Subgroup B) with angiographic ACO were missed (slide 16 results)
- Study wasn’t powered enough to indicate modest benefit of early intervention over late
- Extrapolating results to the real world may be difficult because ecg interpretation
Bottom line/suggested change to practice/actions
- This single center retrospective chart review suggests that considering coronary occlusion vs. just ST elevation on ekg decreases long-term mortality, and has a better sensitivity, specificity, PPV, and NPV.
- This could be a great way of getting patients better access to PCI for occlusive lesions, though inter-operator variability and time constraints are likely to be difficult to implement
Intravenous Alteplase before Endovascular Treatment for Stroke – Journal Club
Dr. Luke Edgar, iFMEM resident
Link to article:
A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke
Methoxyflurane for analgesia in the ED
Dr. Victoria Landry
Link to article
https://pubmed.ncbi.nlm.nih.gov/32989888/
Combining dimer interpretation strategies in suspected PE
Dr. Kendra MacCuspic
PoCUS in pelvic trauma – Journal Club
Severe Agitation in the ED – Journal Club
Alysha Roberts, elective student
Handover from EMS to Trauma Team: an analysis
SJRHEM Journal Club March 29, 2021
Dr. Luke Edgar PGY1 FMEM, Dr. Dan Hines
Dalhousie University Department of Emergency Medicine
PoCUS for Diverticulitis
Dal PoCUS Fellowship – Journal Club – Feb 2021
Dr. Mandy Peach CCFP-EM
PoCUS Fellow
Dalhousie University Department of Emergency Medicine
PoCUS Guided Knee Arthrocentesis
Dal PoCUS Fellowship – Journal Club – Feb 2021
Dr. Melanie Leclerc CCFP-EM
MSK PoCUS Fellow
Dalhousie University Department of Emergency Medicine
Ultrasound-guided versus landmark in knee arthrocentesis: A systematic review
SJRHEM Journal Club Report Oct 2017
SJRHEM Journal Club Report Oct 2017
Allyson Cornelis, R1 iFMEM
Hosted by Dr Andrew Lohoar
Abstract:
Idarucizumab for Dabigatran Reversal — Full Cohort Analysis
Charles V. Pollack, Jr., M.D., Paul A. Reilly, Ph.D., Joanne van Ryn, Ph.D., John W. Eikelboom, M.B., B.S., Stephan Glund, Ph.D., Richard A. Bernstein, M.D., Ph.D., Robert Dubiel, Pharm.D., Menno V. Huisman, M.D., Ph.D., Elaine M. Hylek, M.D., Chak-Wah Kam, M.D., Pieter W. Kamphuisen, M.D., Ph.D., Jörg Kreuzer, M.D., Jerrold H. Levy, M.D., Gordon Royle, M.D., Frank W. Sellke, M.D., Joachim Stangier, Ph.D., Thorsten Steiner, M.D., Peter Verhamme, M.D., Bushi Wang, Ph.D., Laura Young, M.D., and Jeffrey I. Weitz, M.D.
N Engl J Med 2017; 377:431-441August 3, 2017DOI: 10.1056/NEJMoa1707278
BACKGROUND
Idarucizumab, a monoclonal antibody fragment, was developed to reverse the anticoagulant effect of dabigatran.
METHODS
We performed a multicenter, prospective, open-label study to determine whether 5 g of intravenous idarucizumab would be able to reverse the anticoagulant effect of dabigatran in patients who had uncontrolled bleeding (group A) or were about to undergo an urgent procedure (group B). The primary end point was the maximum percentage reversal of the anticoagulant effect of dabigatran within 4 hours after the administration of idarucizumab, on the basis of the diluted thrombin time or ecarin clotting time. Secondary end points included the restoration of hemostasis and safety measures.
RESULTS
A total of 503 patients were enrolled: 301 in group A, and 202 in group B. The median maximum percentage reversal of dabigatran was 100% (95% confidence interval, 100 to 100), on the basis of either the diluted thrombin time or the ecarin clotting time. In group A, 137 patients (45.5%) presented with gastrointestinal bleeding and 98 (32.6%) presented with intracranial hemorrhage; among the patients who could be assessed, the median time to the cessation of bleeding was 2.5 hours. In group B, the median time to the initiation of the intended procedure was 1.6 hours; periprocedural hemostasis was assessed as normal in 93.4% of the patients, mildly abnormal in 5.1%, and moderately abnormal in 1.5%. At 90 days, thrombotic events had occurred in 6.3% of the patients in group A and in 7.4% in group B, and the mortality rate was 18.8% and 18.9%, respectively. There were no serious adverse safety signals.
CONCLUSIONS
In emergency situations, idarucizumab rapidly, durably, and safely reversed the anticoagulant effect of dabigatran. (Funded by Boehringer Ingelheim; RE-VERSE AD ClinicalTrials.gov number, NCT02104947.)
http://www.nejm.org/doi/full/10.1056/NEJMoa1707278
SJRHEM Journal Club Report