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Direct oral anticoagulants in the secondary prevention of stroke and transient ischemic attack in patients with atrial fibrillation
Abstract In patients with non-valvular atrial fibrillation (NVAF) and history of transient ischemic attack (TIA) or stroke, the rate of vascular events is higher in comparison to patients without history of stroke or TIA. A meta-analysis of direct oral anticoagulants (DOACs) studies, including only patients with history of stroke or TIA, report a significant reduction of 15 % in the rates of composite of stroke and systemic embolism in patients treated with DOACs, compared to those treated with warfarin. Furthermore, a reduction of 14 % for major bleeding, as well as a 56 % reduction for hemorrhagic stroke over...
Source: Internal and Emergency Medicine - April 11, 2015 Category: Emergency Medicine Source Type: research

Usefulness of the Admission Shock Index for Predicting Short-Term Outcomes in Patients With St-Segment Elevation Myocardial Infarction
This study investigated using the shock index (SI) as a risk-stratification tool for patients who present within 12 h of symptom onset for acute ST-segment elevation myocardial infarction (STEMI). Using receiver operating characteristic curves, the investigators defined an SI of 0.7 as the cutoff for risk stratification, with a higher number indicating a higher-risk patient. The primary outcomes of the study were all-cause mortality at 7 and 30 days. The secondary outcomes included life-threatening dysrhythmias, heart failure, re-infarction, recurrent myocardial ischemia, stroke, bleeding, and major adverse cardiac events ...
Source: The Journal of Emergency Medicine - January 24, 2015 Category: Emergency Medicine Authors: Spencer Tomberg Tags: Abstract Source Type: research

Improvement of clinical quality indicators through reorganization of the acute care by establishing an emergency department-a register study based on data from national indicators
Background: The Emergency Departments (EDs) reorganization process in Denmark began in 2007 and includes creating a single entrance for all emergency patients, establishing triage, having a specialist in the front and introducing the use of electronic overview boards and electronic patient files. The aim of this study was to investigate the quality of acute care in a re-organized ED based on national indicator project data in a pre and post reorganizational setting. Methods: Quasi experimental design was used to examine the effect of the health care quality in relation to the reorganization of an ED. Patients admitted at N...
Source: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine - November 5, 2014 Category: Emergency Medicine Authors: Maria MattssonNick MattssonHanne Jørsboe Source Type: research

Acute management of ST-elevation myocardial infarction in a tertiary hospital in Kenya: Are we complying with practice guidelines? Phase active de prise en charge des infarctus du myocarde avec élévation du segment ST dans un hôpital tertiaire au Kenya. Les directives pratiques sont-elles respectées?
Conclusion Whereas the majority of STEMI patients are evaluated within 10min of presentation, less than 50% receive reperfusion therapy within the recommended time frame. While there are attempts to comply with evidence based guidelines in resource-limited settings, there is a need to improve acute care systems to target early reperfusion of STEMI patients.
Source: African Journal of Emergency Medicine - October 12, 2014 Category: Emergency Medicine Source Type: research

Dabigatran-related coagulopathy: when can we assume the effect has “worn off”?
This issue of American Journal of Emergency Medicine presents a timely report that should be noted by all practicing emergency physicians. Nzwalo et al [1] describe a 61-year-old man with nonvalvular atrial fibrillation, taking 150 mg dabigatran twice daily for stroke protection, who presented to their emergency department (ED) with an acute ischemic stroke (AIS). The patient had a normal creatinine clearance and a normal thrombin time (TT). He was treated with intravenous recombinant tissue plasminogen activator (rt-PA) with good neurologic outcome and no bleeding complications.
Source: The American Journal of Emergency Medicine - August 28, 2014 Category: Emergency Medicine Authors: Charles V. Pollack, Jerrold H. Levy, John Eikelboom, Jeffrey I. Weitz, Frank W. Sellke, Menno V. Huisman, Thorsten Steiner, Pieter Kamphuisen, Richard A. Bernstein Tags: Controversies Source Type: research

Drug for Clot in Lung Helps -- at a Price (CME/CE)
(MedPage Today) -- A shot of thrombolytic therapy substantially improved outcomes in intermediate-risk pulmonary embolism in a randomized trial, but the improvement came at a price in bleeding and stroke that is likely to keep acceptance low.
Source: MedPage Today Emergency Medicine - April 9, 2014 Category: Emergency Medicine Source Type: news

Rate-control versus Rhythm-control Strategies and Outcomes in Septuagenarians with Atrial Fibrillation: Shariff N, Desai R, Patel, K, et al. Am J Med 2013;126:887–93.
Using data based on a public-use copy of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, the authors analyzed a subgroup of 70–80-year-old patients to compare rhythm vs. rate-controlling strategies. Of the 4060 patients from the original trial, 2248 patients were 70–80 years of age; 1118 were in the rate control group. Propensity-matching scores were used for each of the 2248 patients and they were placed in a cohort of 937 pairs, balanced using 45 baseline characteristics. Outcomes were all-cause mortality as the primary end point and cause-specific mortality, all-cause and cause-s...
Source: The Journal of Emergency Medicine - February 27, 2014 Category: Emergency Medicine Authors: Justin McLean Tags: Abstracts Source Type: research

Management of Dabigatran-associated Intracerebral and Intraventricular Hemorrhage: A Case Report
Conclusion: Due to lack of an available antidote, activated prothrombin complex concentrate was utilized as a nonspecific procoagulant to stabilize an intracerebral hemorrhage in a patient on dabigatran.
Source: The Journal of Emergency Medicine - February 10, 2014 Category: Emergency Medicine Authors: Andrew C. Faust, Evan J. Peterson Tags: Pharmacology in Emergency Medicine Source Type: research

The acute management of haemorrhage, surgery and overdose in patients receiving dabigatran
Dabigatran is an oral direct thrombin inhibitor (DTI) licensed for stroke prevention in atrial fibrillation and likely to be soon approved in Europe for treatment of venous thrombosis. Predictable pharmacokinetics and a reduced risk of intracranial haemorrhage do not negate the potential risk of haemorrhage. Unlike warfarin, there is no reversal agent and measurement of the anticoagulant effect is not ‘routine’. The prothrombin time/international normalised ratio response to dabigatran is inconsistent and should not be measured when assessing a patient who is bleeding or needs emergency surgery. The activated p...
Source: Emergency Medicine Journal - January 15, 2014 Category: Emergency Medicine Authors: Alikhan, R., Rayment, R., Keeling, D., Baglin, T., Benson, G., Green, L., Marshall, S., Patel, R., Pavord, S., Rose, P., Tait, C. Tags: Poisoning/Injestion, Open access, Drugs: cardiovascular system, Stroke, Poisoning Review Source Type: research

New oral anticoagulants: An emergency department overview
Abstract As of September 2013, three new oral anticoagulants (NOACs) are now available for clinical use on the Pharmaceutical Benefits Scheme in Australia. All three are for stroke prevention in atrial fibrillation, and one will also be available for the treatment of deep venous thrombosis and pulmonary embolism. All have been evaluated in large, multicentre randomised clinical trials. These drugs show at least equivalent efficacy to the current standard of care, the vitamin K antagonist warfarin. Major bleeding rates are overall comparable with warfarin, but there is an important reduction in intracranial bleeding of appr...
Source: Emergency Medicine Australasia - November 13, 2013 Category: Emergency Medicine Authors: Peter Wood Tags: Short Report Source Type: research

In reply
Dr. Ellison likens tissue plasminogen activator (tPA) treatment for ischemic stroke to a lottery. In a sense, he is correct. As with any therapy, the outcome for any particular tPA-treated patient cannot be predicted with certainty. Patients may improve because of the intended effect of the drug, experience no change, or, less commonly, experience harm because of bleeding.
Source: Annals of Emergency Medicine - September 20, 2013 Category: Emergency Medicine Authors: Jonathan A. Edlow, Eric E. Smith Tags: Correspondence Source Type: research

The anticoagulation of calf thrombosis (act) project: results from the randomised controlled external pilot trial
Conclusion We have established feasibility for a definitive trial on the value of therapeutic anticoagulation for IDDVT. Our pilot study currently provides the largest prospective randomised clinical dataset on this topic and demonstrates a non-significant trend towards reduction in complications with anticoagulation.
Source: Emergency Medicine Journal - September 7, 2013 Category: Emergency Medicine Authors: Horner, D., Hogg, K., Body, R., Nash, M. J., Mackway-Jones, K. Tags: Drugs: cardiovascular system, Stroke, Venous thromboembolism, Pulmonary embolism DAY 2: ROD LITTLE PRIZE: THE LIVE ROOM, 15:30-17:00 Source Type: research

Managing Bleeding in Anticoagulated Patients in the Emergency Care Setting
Conclusions: The introduction of alternative oral anticoagulants will require emergency procedures that differ in some respects from those currently in place for warfarin and it will be necessary for Emergency Medicine professionals to become familiar with these procedures. Clinical stabilization of the bleeding or at-risk patient remains the emergency physician’s priority.
Source: The Journal of Emergency Medicine - June 19, 2013 Category: Emergency Medicine Authors: Charles V. Pollack Tags: Clinical Reviews Source Type: research

Validation of the San Francisco Syncope Rule in Two Hospital Emergency Departments in an Asian Population
ConclusionsIn this study, SFSR rule had a sensitivity of 94.2%. This suggests caution on the strict application of the rule to all patients presenting with syncope. It should only be used as an aide in clinical decision‐making in this population. Resumen Validación en una Población Asiática de la Escala de Síncope de San Francisco en Dos Servicios de Urgencias HospitalariosObjetivesValidar externamente la capacidad de la Escala de Síncope de San Francisco (San Francisco Syncope Rule (SFSR)) para identificar con certeza los pacientes que experimentarán un evento clínico grave a los 7 días siguientes en una poblac...
Source: Academic Emergency Medicine - May 14, 2013 Category: Emergency Medicine Authors: Camlyn Tan, Tiong Beng Sim, Shin Ying Thng Tags: Original Research Contribution Source Type: research

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