ACEP 2016 Cruising the Literature Cardiology 2016 VanderbiltEM.com Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN ACLS 2016 147 references The new AHA 2016 Guidelines for ACLS 15 writing groups All based on 2015 ILCOR topics Oxygen Use Use 100% O 2 during CPR But not after ROSC 93-95% if well performed 89-92% if COPD BVM vs SGA vs ETT No high quality evidence to favor any ETI may decrease compression fraction For healthcare providers trained in their use either an SGA or ETT may be used as the initial airway during CPR 1
Assessment of ETT Placement Continuous waveform capnography is recommended for placement and monitoring If not available then colorimetric, EDD or ultrasound may be used Ventilation Rate 10 breaths per minute (Q 6 seconds) after advanced airway in place Antiarrhythmic for VF/pVT Amiodarone may be considered Lidocaine may be considered as alternative Magnesium not recommended No antiarrhythmic as yet been shown to increase survival or neurologic outcome after cardiac arrest due to VF/pVT New Engl J Med 2016; 374:1711-22 What is the best antiarrhythmic for shock resistant VF/pVT: Amiodarone vs Lidocaine vs Placebo? 3,026 pts., 10 ROC sites Randomized, double blind, placebo controlled VF/pVT, s/p 1 or more shocks, s/p epi Only adult medical VF/pVT OOH Average age 63 ± 14 y; 80% M 60% had bystander CPR BLS in 5.8 min ALS in 8 min EMS call to drug: 19 min (prior trials 21-25 min) New Engl J Med 2016; 374:1711-22 Survival to Discharge Neurologic Outcome New Engl J Med 2016; 374:1711-22 % 30 24.4 23.7 21 25 18.8 17.5 16.6 20 15 10 5 A L P A L P 0 Survival Mod Rankin 3 2
Percentage Differences Amiodarone vs Placebo Amiodarone vs Lidocaine Lidocaine vs Placebo Amiodarone vs Placebo Modified Rankin 3 Amiodarone vs Lidocaine Modified Rankin 3 New Engl J Med 2016; 374:1711-22 3.2% (p=0.08) 0.7% (p=0.70) 2.6% (p=0.16) 2.2% (p=0.19) 1.3% (p=0.44) NEJM 2016:375;801-3 Authors Note in Letter to Editor 5% absolute improvement of Amiodarone over placebo (p 0.04) if arrest witnessed (1934 pts) 21.9% absolute increase Amiodarone vs placebo if EMS witnessed and gave drugs near immediately (p < 0.01 for 154 pts) Resuscitation 2016;107:31-7 What do all studies combined tell us about Amiodarone vs Lidocaine in VF/pVT? 7 studies: 3 RCTs, 4 non-rcts 3,877 pts in RCTs and 700 in non-rcts Includes 2016 NEJM trial Admission and Discharged Alive evaluated Results Resuscitation 2016;107:31-7 Amiodarone vs Placebo: - trend for hospital discharge with Amio (p=0.08) - No difference in favorable neuro outcomes Lidocaine vs Placebo: - No significant difference at discharge Amiodarone vs Lidocaine: - No difference in hospital discharge (p=0.81) Amiodarone vs Lidocaine vs Placebo There is no strong evidence on antiarrhythmic efficacy in VF/pVT If 3% superiority of Amiodarone over placebo was true difference (requires larger study) then 1,800 lives would be saved in North America yearly The data is not conclusive At the present time, there is no clear benefit of Amiodarone vs Lidocaine Late in VF it s not clear either drug is beneficial The drugs are given 10-20+ minutes into arrest 3
Tachycardia Termination vs Side Effects 67% Eur Heart J 2016; June 28 Epub ahead of print Eur Heart J 2016; June 28 Epub ahead of print Is amiodarone really the best antiarrhythmic for VTach / Wide complex QRS tachycardias? Randomized European trial of 62 patients 10 mg/kg of procainamide over 20 minutes (33 pts.) 5 mg/kg of amiodarone over 20 minutes (29 pts.) All had BP > 90 mm Hg and no SOB Evaluated both efficacy and major adverse events 60% Hundreds70% 50% 40% 30% 20% 10% 0% 41% 38% P=0.026 9% Pro Amio Pro Amio Termination Major Adverse Effects P=0.006 Hypotension Eur Heart J 2016; June 28 Epub ahead of print Hypotension common with both drugs 41% of amiodarone required immediate cardioversion Less than 1/10 (9%) in procainamide group required emergency cardioversion Total adverse events double with amiodarone (48% vs 24%) Amiodarone vs Procainamide for VTach Procainamide clearly superior in this study and much less toxic Amiodarone dose of 5 mg/kg is about 300 mg which is double the 150 mg/10 minutes But even with high dose amiodarone, procainamide much more efficacious My bias is to not use amio in stable wide complex patients and I use procainamide as my antiarrhythmic of choice Stable Wide Complex Tachycardia 5 Steps Be sure it is regular Modified Vagal Maneuver Adenosine: 12 mg IVP Procainamide: 100 mg/min x 2 then 50 mg/min x 5 Shock 4
% 50 45 40 35 30 25 20 15 10 5 0 Valsalva Effectiveness (n=214 each group) 15% Standard Lancet 2015;386:1747-53 47% Lie back, Legs up p < 0.0001 or = 4.9 Use not addressed during VF/pVT Inadequate evidence to support post CPR use May be considered Beta Blockers Not enough evidence to be for or against lidocaine or beta blockers s/p VF/pVT Vasopressin Vasopressin + Epi no longer recommended Vasopressin no longer recommended Vasopressin has been removed from ACLS algorithm Epinephrine Use Standard dose epinephrine (1 mg Q 3-5 minutes) may be reasonable for patients with cardiac arrest (class 11b) Early administration may improve ROSC and neurologic outcomes later administration may decrease both BMJ 2016;353:1577-87 Does giving epinephrine before 2 nd shock help or hinder resuscitation? 2,974 VF/pVT arrests, 1,510 with epi < 2 min Inpatient data from 300 GWTG-R hospitals Propensity matched cardiac arrest pts Compared epi before vs after 2 nd shock BMJ 2016;353:1577-87 51% of patients received epi before 2 nd shock 87% of both groups received 2 nd defib Groups equal for total defibrillations (3) Early epi group received 3 mgs or epi on average vs 1 mg in later dosing Similar TOR times (22 vs 21 mins) 5
Epi Before vs After 2 nd Shock BMJ 2016;353:1577-87 79% % 67% 80 All p < 0.001 70 48% 60 41% 50 31% 40 25% 30 Early Epinephrine Administration Wait for second shock before administering epinephrine The role of epi is still not clearly defined but wait to administer it 20 10 0 < 2 > 2 min < 2 > 2 min < 2 > 2 min Epinephrine is the most potent cardiac stimulant wait to give it during VF ROSC Survival Good Neuro Techniques Tried with Defibrillation Resuscitation 2016;103:37-40 Bare handed Resuscitation 2016;103:37-40 Can we safely perform hands-on defibrillation? Blinded cadaver study 6 different techniques tried 360 joules used (only 30 for bare handed) Ten volunteers Single layer nitrile gloves Double nitrile gloves Firefighter gloves Neoprene pad Manual compression/decompression Hands on Defibrillation Another study shows it is possible All detected bare handed shock Resuscitation 2016;103:37-40 1% of all other shocks detected 0.2% shocks detected with single layer glove 0.6% with double layer gloves detected No shock detected with firefighter gloves Thick gloves likely block any current leak Not a safety study, no current leak measured Hands-on continues to look feasible 6
Steroids There is no recommendation for or against steroids for in-hospital cardiac arrest Use of steroids in out-of-hospital arrests are of uncertain benefit Chest Pain R/O AMI Circulation 2016;134:547-64 Published August 16, 2016 Truly State of the Art A Must Read Reviews the accuracy of - Hx - Troponin - PE - Rule out protocols -ECG Symptoms pre Sudden Death Annal Int Med 2016;164:23-9 Is Sudden Death really sudden in middle aged adults (35-65 yo)?? 839 sudden cardiac deaths from Oregon In depth review of victims prior 4 weeks Family, friends, med records & survivors questioned CP, SOB, palpitations, syncope, N/V, back pain?? 51% had at least one symptom in preceding 4 weeks of SCA (M = F) Of these, almost ½ had CP (46.3%, 2:1 M vs F) 18.1% had SOB (2:1 F vs M) 2/3 of pts ignored symptoms Annal Int Med 2016;164:23-9 Almost all (93%) had sx or worsening within 24 hours of their cardiac arrest 7
Sudden Death Half of patients with SCA are symptomatic within 4 weeks of their arrest Be careful in your C.P. evals Most have new or worse symptoms within 24 hrs Ruling out AMI Is 1 hour possible? Atypical is Typical 1,282 CP pts in multinational study 16.2% had AMI Divided pts into 3 groups Used a 0 hour and a 1 hr troponin Annals of Emerg Med 2016;68:76-87 Can a 0 and 1 hour delta troponin rule out protocol using High Sensitivity Troponin T accurately triage CP patients? Methods Annals of Emerg Med 2016;68:76-87 Used hs-ctnt of < 12ng on ED entry And a 1 hour below 3ng to R/O AMI Divided patients into 3 groups AMI; Ruled-out; Observational R/O AMI groups Accuracy Observational Group 22.2% AMI 14.4% Annals of Emerg Med 2016;68:76-87 AMI Ruled Out Observational Group NPV for R/O 99.1% (98.2-99.7) 20% of observational group had AMI NPV for R/O 99.1% (98.2-99.7) Ruled Out 63.4% Sensitivity for AMI 96.7% (93.4-98.7) 7 / 813 false negatives (0.86%) 8
JAMA Cardiol 2016;1:397-404 Can we R/O AMI accurately and safely within 1 hr? 1,040 pts in study group; Abbott hs Trop I Validated with 2 independent cohorts Compared 1 hr R/O to 3 hr R/O Didn t use standard 99 th % cutoff 99% = 27 ng/l; used lower value of 6 ng/l Methods JAMA Cardiol 2016;1:397-404 Study protocol use 0 and 1 hr Compared to 0 and 3 hr NSTEMI = Troponin 6 ng/l at 0 or 1 hr Compared to 0 and 3 hours Did 1 yr follow-ups on mortality Results JAMA Cardiol 2016;1:397-404 The 1 hr R/O = 3 hr R/O NPV of negative Trop rise > 99% (99.8) Sensitivity to R/O Men = 98.3% (93.9 99.8) Sensitivity to R/O Female: 100% (90.3 100) 1 Hour AMI Rule Out Protocols Works as well as 0 and 3 hr R/O Both techniques miss 1-2% of NSTEMI Studies did not use any CP score system Note: uses hs Trop and lower positive value 1 hr R/O coming.not yet and not perfect Annal Emerg Med 2016;68:295-7 Annal Emerg Med 2016;68:295-7 Is one Troponin good enough to R/O AMI? Meta-analysis of 23 studies, 9,428 pts Age range 54-71 years old Median symptom onset 3.5-5.6 hours Authors note time of sx onset affects validity In high-risk chest pain patients, a single, normal, high-sensitivity troponin T level identifies those who are very unlikely to have acute myocardial infarction, yet the optimal diagnostic threshold and timing remain unclear The potential benefits and harms of adopting a single troponin strategy in the context of the entire spectrum of ACS and among lower-risk patient populations requires further study 9
AJR 2016;207:295-301 Is the Triple-Rule-Out real or just a huge amount of radiation and not as good as a single focused exam? 1,196 cases using 256-MDCT scanner 4 cases inadequate study AJR 2016;207:295-301 139/1194 or 8.9% had another cause of CP 81.4% had negative study for significant disease 11.7% had significant coronary dsx ( 50% stenosis) AJR 2016;207:295-301 Non-CASHD findings Pulmonary embolism in 28 pts (2.3%) Aortic aneurysm in 24 pts (2.0%) Pneumonia in 20 pts (1.7%) Routine CTA would have missed 27.3% of all pulmonary emboli and aortic pathology Endocarditis, Tamponade, Ulcer, PTX, Dissection, Metastatic disease seen 528 Incidental findings unrelated to CP (35.1%) Triple Rule Out Triple Rule Outs coming as higher level scanners come to our medical centers Find almost 1 in 10 other causes for CP STEMI and NSTEMI 5.3 msv is higher than 1-2 msv used for coronary CTA 10
STEMI BP Changes Post NTG Prehosp Emerg Care 2016;20:76-81 23.4 23.9 25% Prehosp Emerg Care 2016;20:76-81 How dangerous is NTG in Inferior AMI? 20% 1,466 STEMIs, 56% received NTG 15% 8.2 8.9 P=NS P=NS Montreal Quebec EMS 2010-2012 10% Evaluated BP changes in Inf vs Non-Inf AMIs 5% BP < 90 or BP > 30mm Hg s/p NTG 0% Inf Not-Inf Inf Not-Inf BP < 90 BP > 30mm Hg Hypotension S/P NTG in AMI Common up to ¼ pts of all STEMIs Study does not show an increase in Inferior AMI vs Non-Inferior AMI Be careful in all AMI pts who receive NTG JAMA Intern Med 2016;176:1211-2 Reviews new LBBB activation criteria New or presumed new LBBB X= STEMI LBBB = STEMI if Acute Heart Failure or Hypotension 1 mm concordant 5 pts ST V 1-3 3pts Troponin returns positive Positive modified Sgarbossa criteria ( 3 points) 5 mm discordant 2pts 11
LBBB and STEMI Stable new LBBB and CP do not equal STEMI wait on troponin Know modified Scarbossa criteria Lytics vs Lab Beware 5 mm discordant ST it s not enough and easy to use to overcall an MI 2,470 pts: 90% PCI, 10% TNK All pts had sx 2 hours Evaluated 30d mortality Catalonia Spain Euro Heart J 2016;37:1034-40 Are lytics superior to PCI in acute STEMI when PCI is not available and transfer is required? Immediate TNK vs Transfer for PCI Mortality if sx < 2 hrs old 8% 7% 6% 5% 4% 3% 2% 1% 0% 7.7% TNK 5.1% PCI Euro Heart J 2016;37:1034-40 P=0.09 9% 7.7% 8% 7% 6% 5% 4% 3% 2% 1% 0% Time to PCI vs TNK TNK 2% P<0.01 Euro Heart J 2016;37:1034-40 4.6% p=0.03 8.3% <99 min 99-140 > 140 PCI ns Lytic vs Lab in Acute STEMI PCI is superior in acute STEMI Even if delay to PCI takes 2 hrs Higher bleeding rates with lytics (3.7% vs 1.6% Transfer unless you anticipate a prolonged delay > 140 minutes for PCI 12
PE Therapy Chest 2016;149:315-52 The most current state of the art recommendations for PE and DVT therapy and prophylaxis Recommends NOACs over warfarin No therapy recommended for subsegmental PEs PE therapy recommendations for lytic vs LMWH No recommendations; however, are based on high-quality evidence Chest 2016;149:315-52 PE Rx Recommendations Systemic thrombolysis recommended only for hypotension (< 90 mn hg) Even if RV > LV by echo and positive troponin Systemic lytics recommended over catheter infusion Only if high bleeding risk and hypotension is CDT recommended over systemic lytics Cath and Card Interventions 2015;86:1219-27 Is systemic or CDT directed lysis superior for PE? 1,521 PE pts treated with thrombolysis National inpatient sample 2010-2012 Propensity matched study of 352 CDT pts Evaluated mortality; ICH and mortality 25% Systemic vs CDT PE Lysis 21.81% Cath and Card Interventions 2015;86:1219-27 1.6% Total ICH (all pts) Systemic Lytics vs CDT 1.37% Cath and Card Interventions 2015;86:1219-27 20% 13.36% 1.4% 1.2% 15% P<0.001 1.0% P=0.09 10% 5% 1.38% 0% P=0.08 0.8% 0.6% 0.4% 0.2% 0.28% 0% IV Mortality CDT IV CDT 0.0% ICH IV CDT 1,169 pts 352 pts 13
Lytic Therapy for PE Who gets what is still unclear Refractory hypotension is absolute indication IV currently recommended over CDT (unless bleed high risk) Are lytics proven to be effective in cardiac arrests due to PE? Much controversy though and emerging CDT evidence Young healthy pt, submassive PE, + trop, + RV > LV: not sure what s best, my bias is lytic Am J Emerg Med 2016;34:1963-7 Is TPA effective in PEA arrests due to a massive PE? The PEAPETT study 23 consec pts with confirmed massive PE and PEA 17 ED pts, 3 in Radiology, 2 ICU, 1 Floor 16/23 PE diagnosed before arrest All treated with 50 mg TPA over 1 minute Heparin then given: 2,000-5,000 bolus Results Am J Emerg Med 2016;34:1963-7 CPR to lytic time was 6.5 min (± 2.1 min) 22/23 regained a pulse within 2-15 min No minor or major bleeding PA pressures dropped from 58 to 40 at 48 hrs 20/23 alive at 22 months Lytics for PEA and PE If PEA is due to, or believed due to, a PE use TPA during CPR 50 units over 1 minute Great results in this trial of proven or suspected PE Hypertension No proven benefit for undifferentiated PEA PEA overall survival = 2-4%; with lytics to 80-90% at 2 years!! 14
JAMA 2014;311:507-20 Newly revised BP guidelines for 2014 140 / 90 is now goal < 60yo 150 / 90 is now goal > 60yo New drug choice recommendations Optimal treatment of your and your patient s BP Per Year Incidence AMI, CVA,HF, Death NEJM 2015;373:2103-16 3% 2.19% 25% P<0.001 NEJM 2015;373:2103-16 Does aggressive BP control to 120 mm Hg systolic make a difference? 9,361 pts age 75 with CVD risk compared target below 120/80 vs accepting 140/90 Randomized controlled open label study Evaluated rates of AMI, CVA, HF and death 2% 1% 0% Std BP Control 1.65% Aggressive Management Summary Summary Dial back O 2 post ROSC Antiarrhythmics not great for VF Epi in VF after shock 2 not before 1 hour rule-outs coming NTG causes BP in all AMIs New LBBB STEMI PCI > lytics up to 2 hr Increasing use of CDT for PE Use lytics for PE induced PEA BP 120/80 again 15
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