Cardiology, Improving Outcomes, Improving Throughput

A chicken in every pot, and a cardiologist in every box.

I think the HEART score is useful, and an incredible start to getting everyone on the same page. Getting both an ED and consultant group to universally agree on a protocol, and implement observation / admission protocols off of it are probably a bit more difficult.

And this is only with a few “soft” variables– what exactly differentiates slightly from moderately suspicious anyway? As we all know, stories change (and not just from patients!).

This paper retrospectively looked at 6 months worth of ED chest pain charts which had a cardiology consult and tries to extract a HEART score based off the ED documentation as well as the cardiology consultation.

Unfortunately the retrospective nature and lack of a standardized “flow sheet” for history probably greatly contributes to cardiology/EP disagreement in the HEART score (like, say, documenting tobacco usage in the chart). History between EP and cardiology was in agreement 47% of the time, EKG interpretation agreement at 76%, and risk factor agreement at 85%. Overall HEART score agreement between EP’s and cardiology occurred 70% of the time, primarily with some mixture of cardiology consistently downplaying elements and/or EP’s upselling some.

Of those who had a phone consultation with cardiology, only 5.4% were discharged, vs 45% discharged when physically seen by cardiology. Only 9% were admitted after in-person cardiology evaluation vs 77% for those with phone consultation. Of those who received further testing, 45% of the cardiology phone consultations were discharged, vs 87% discharge rate for those who received additional testing after an in-person cardiology consultation…. Seems like cardiology is scared to discharge without seeing the patient, and that we are probably upselling the patient a bit.

Regardless, this is hypothesis generating at best, particularly with such low numbers to evaluate (33 patients evaluated by cardiology and EP’s over this 3 month period!), and frankly, the retrospective data extraction without a clear checklist for HEART scores makes me question the validity of their conclusions. Nonetheless, I hold hope that cardiology and EM can live in harmony at some point in the future.

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Improving Outcomes, Mythbusting, Pulmonary

Sono-guided ACLS

This study demonstrates what many of us have probably suspected – the absence of cardiac activity on ultrasound portends a grave diagnosis; but this study really is so much more.

Utilizing 20 sites across the US and Canada from May 2011-Nov 2014 looked at all nontraumatic in-ED and out of hospital cardiac arrests that arrived to the ED in either PEA or asystole, and whether or not POCUS demonstrated a potential role in resuscitation.

953 patients, 793 used for final analysis (106 not included due to resuscitation under 5 minutes, 8 patients DNR, 1 uninterpretable sono, 3 with incomplete timing data, 42 for no ACLS meds given) – had a cardiac sono at the “beginning and end of ACLS.” The primary outcome was percentage of patients that survived to hospital admission, with secondary outcomes of survival to discharge and ROSC. Unfortunately, neurologic intact survival was not evaluated. The treating EP’s were credentialed in POCUS at their local institutions and unblinded. Digital clips were reviewed by a single reviewer in a blinded fashion for agreement (which was deemed to be “substantial agreement”).

The data (numbers are percentage, such that “28.9” = the percentage of patients with cardiac activity on POCUS during the resuscitation who survived to admission):

screen-shot-2016-10-05-at-8-42-01-pm

 

Cutting to the chase, this study brings up a number of key points:

-PEA on the monitor may not necessarily be PEA, with a whopping 54% of patients having cardiac activity on POCUS

-asystole on the monitor may not be cardiac standstill, as 10% had cardiac activity on POCUS

– survival to admission with cardiac activity on POCUS is MUCH higher – 28.9% vs 7.2%, but….

– cardiac activity on POCUS for PEA/asystole portends only a 3.8% survival to discharge

-no cardiac activity = poor prognosis, 0.6% of patients survived (3 out of 530). With two of the three patients were Vfib at some point during EMS working on them.

-pericardial effusion was seen in 34 patients (4.3% of those in the final analysis). 15.3% of patients whom had a pericardiocentesis performed survived to discharge.

– only 15 patients received lytics for suspected PE, with only one (6.7%) surviving to discharge. (which was almost the MORTALITY rate of PEAPETT)

 

Whew. This is a lot to digest. Let’s just say that ultrasound helps you tease out a spectrum of disease and further characterizes what you are dealing with. I’m looking at POCUS in codes as a risk stratification tool. Is there a prolonged time without cardiac activity without a potentially reversible causes? Might want to consider calling it earlier since survival to discharge is abysmally low. And sheesh… 1 out of 25 cardiac arrests had a pericardial effusion??? Wow. Time to brush up on those pericardiocentesis skills.

Caveats- this was done by EP’s credentialed for POCUS, so they’re likely more talented than the rest of us.  Dont let that scare you though, rather, this.  Perhaps seeing cardiac movement on ultrasound lends a “bridge to hope” and the team puts in a more-heroic-than-usual effort.

And of course, this also leads to more questions- of those 28.9% with cardiac activity that survive to admission, what if they are brought straight to the cath lab? Or started on ECMO? Would this potentially alter survival rates and neurologically intact survival in meaningful ways? Time shall tell.  Until then, cut that KT window, pick up the probe, and have your TPA & long pericardiocentesis needle ready.

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Cardiology, Improving Outcomes, Mythbusting, Neurology

Chronic viral infection & Coronary disease.

Are you openly ignoring a cardiac risk factor that is in the ballpark of smoking or early family history?   Even after controlling for numerous factors, well controlled HIV has a significantly higher cardiovascular MORTALITY rate – with an adjusted rate ratio of 1.53, while poorly controlled patients even moreso, with an adjusted rate ratio of 3.53, according to this paper.  It should be noted that this is one of several papers looking into HIV as a risk factor for early cardiac disease and death.

It is important to realize the limitations of our tools that we have at our disposal.  For instance, PERC and HEART are not validated in an HIV population.

I suspect many if not all chronic viral infections will portray a similar trend. It is already seen in HepC, albeit to a lesser extent. It will be interesting to see if the new age HepC drugs decrease the known risk of increased coronary artery disease and cerebrovascular disease after treatment.

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Cardiology, Critical Care, Improving Outcomes

Brady arrest? Go Full Bore.

Do you believe in full bore medicine?

(hat tip to SMACCdub for that line)

This paper puts those thoughts under the microscope a bit, and challenges us to think ahead and be prepared.

They looked at all OHCA from 2006 to 2012 with initial brady/asystolic arrests to determine if they may benefit from pre-hospital pacing, and to look at survival rates associated with various rhythms. Clear non-cardiac causes (trauma, drowning, respiratory, neurologic, suicide) were excluded.

7925 OHCA in the Netherlands

less non-cardiac (6681 patients)

less those without EKGs (~500 patients)

less ~3000 patients with VF/VT (now at 2643 patients)

less those with normo/tachycardia and those with pacers previously placed (~300 patients)

 

This leaves us with 2333 brady/asystolic (idioventricular, junctional, sinus brady, 3rd degree with/without escape, asystole) patients – or, about 30% of their OHCA.

Unwitnessed arrest still protends a poor outcome, with survival about 0.5%. However, for witnessed arrests, they report 4% survival for idioventricular / junctional arrests and 6.8% for sinus brady arrests. This seems consistent with prior studies. However, for a study trying to determine whether or not pacing is beneficial, their pace rates were quite low. They paced 11 of 220 sinus brady patients and 41 of 452 idioventricular / junctional patients, with a delay of 30.1 and 16.5 minutes to pacing respectively – with an electrical capture rate of 55% and 70% to boot.  Esssentially, they can’t answer the question “Does pacing help” with such a care gap.

So, why is this? For sinus brady, maybe patients are hanging in the 40’s-50’s and felt to be quasi-stable. Maybe its the angst of floating a pacer. Perhaps the lengthy delay for sinus brady is giving atropine, then giving it again… and maybe again- akin to pressor-angst for sepsis (giving a 4th, 5th, and 6th liter rather than starting pressors or a central line).  I imagine there is a mental barrier – whether it be not thinking about pacing or passing the buck (“I’ll let the ICU figure it out.”). The evolution of the ED-ICU model (and perhaps UPMC’s cardiac arrest unit) may be the best place to look at this type of “full bore” medicine and whether or not it would be beneficial.

But for now, there is a large gap in care. Bradycardic arrests represent about 10% of arrests, have a reasonable survival rate, and are (potentially) suboptimally managed – and you have the tools to potentially improve an outcome.  We can not say whether or not pacing is futile care for this condition.

Until then, go full bore. Your patients & their families deserve it until pacing is demonstrably shown to not be beneficial in bradycardic arrests.

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Cardiology, Critical Care, Improving Outcomes, Improving Throughput, Radiology

POCUS, Aneurysms, and Mortality Rates.

If you’re a #FOAM follower, you have probably seen the pleas for bedside ultrasound more than once. This paper takes an interesting approach to try and demonstrate its value in the diagnosis of aortic dissection: Over a two year period and 386,547 patient visits, there was a review of 123 medical reports and 194 autopsy reports, of which 32 patients were identified for inclusion. 16 received EP POCUS, 16 did not.

Median time to diagnosis – 80 minutes in the POCUS group vs 226 minutes in the non POCUS group. Misdiagnosis was 0% in the POCUS.

Mortality adjusted for DNR status: 15.4% vs 37.5%, POCUS vs non-POCUS.

Time to dispo? 134 minutes vs 205 minutes, POCUS vs non-POCUS. (and probably a much greater difference in time to *appropriate* disposition.)

[note that neither mortality or time to dispo was statistically significant] 

With that said, I agree with the authors conclusions, (particularly in light of this previous post): “Patients who receive EP FOCUS are diagnosed faster and misdiagnosed less compared with patients who do not receive EP FOCUS. We recommend assessment of the thoracic aorta be performed routinely during cardiac ultrasound in the emergency department.”

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Cardiology, Mythbusting

Holiday Heart is Real

I wanted to put this one out early this year, even though the paper was published in 2014.

An analysis of 12,195 cases of first MI (spanning 52 countries!) was compared to 15,583 age and sex-matched controls. While they found that frequent alcohol use in moderation was associated with a reduced risk compared to non-drinkers (OR 0.87), heavy episodic drinking (six or more drinks) within a 24 hour period was associated with an increased risk of MI (OR 1.4).

This risk was significantly elevated in those over age 65 with an OR of 5.3 !

Take home – Holiday Heart is real, don’t blow it off as GERD if they show up in your ED, and don’t let your elders drink then go shoveling this holiday season!

Enjoy the holidays safely!

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Cardiology, Improving Outcomes, Improving Throughput

The Lean ED in the Obs Unit

The “lean ED” has been embraced in multiple ways – keep your vertical patients vertical, a disposition area where patients await paperwork & final signatures, bedside sono, the list goes on.

It would stand to reason that lean principles would trickle down the halls and up the elevator to other departments as well.  Along these lines, I’ve started to see ultrasound trickle into the hands of internal medicine residents with good results:

This study (http://www.ncbi.nlm.nih.gov/pubmed/25492052), after just 9 hours of training, focused cardiac ultrasound allowed for “substantial” agreement between trainee and tutor for identification of pericardial effusion (k=0.71) and global cardiac systolic function (k= 0.77), “moderate” for marked right and left ventricular enlargement (k= 0.56-0.64).  After an additional 9 hours of training, residents were only proficient in obtaining adequate images in the parasternal window without mastering the apical and subcostal views.

While here (http://www.ncbi.nlm.nih.gov/pubmed/26179460), ten internal medicine attending physicians performed focused cardiac ultrasound on178 inpatients and compared to formal echo interpreted by cardiologists.  Sensitivity and specificity for any degree of left ventricular systolic function was 91% and 88% respectively.  The interrater agreement between the internist and cardiologist was “good/substantial” with K = 0.77.

These principles can and should be applied to observation units, where many chest pain rule outs and CHF exacerbations will be placed – and along with them, orders for an echo (I’ll leave the discussion of whether or not they all need an echo for another day).  I’ve waited until the next day for an echo to be done and read in an observation unit so I can dispo a patient.  If you are working in observation regularly, and chest pain and CHF is your bread and butter, I see no reason why echo competency can not be obtained rather quickly.  By learning bedside cardiac sono as an observation unit provider, you’ll make yourself an invaluable team member and likely decrease length of stay without harming patients.

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