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Sigle M, Faller W, Heurich D, Zdanyte M, Wunderlich R, Gawaz M, Müller KAL, Goldschmied A. Machine learning predicts emergency physician specialties from treatment strategies for patients suspected of myocardial infarction. Int J Cardiol 2024; 413:132332. [PMID: 38964547 DOI: 10.1016/j.ijcard.2024.132332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 06/03/2024] [Accepted: 07/01/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Our investigation aimed to determine how the diverse backgrounds and medical specialties of emergency physicians (Eps) influence the accuracy of diagnoses and the subsequent treatment pathways for patients presenting preclinically with MI symptoms. By scrutinizing the relationships between EPs' specialties and their approaches to patient care, we aimed to unveil potential variances in diagnostic accuracy and treatment choices. METHODS In this retrospective, monocenter cohort study, we leveraged machine learning techniques to analyze a comprehensive dataset of 2328 patients with suspected MI, encompassing preclinical diagnoses, electrocardiogram (ECG) interpretations, and subsequent treatment strategies by attending EPs. RESULTS We demonstrated that diagnosis and treatment patterns of different specialties were distinct enough, that machine learning (ML) was able to differentiate between specialties (maximum area under the receiver operating characteristic = 0.80 for general medicine and 0.80 for surgery). In our study, internist demonstrated the highest accuracy for preclinical identification of STEMI (0.96) whereas surgeons showed the highest accuracy for identifying NSTEMI. Our findings highlight significant correlations between EP specialties and the accuracy of both preclinical diagnoses and subsequent treatment pathways for patients with suspected MI. CONCLUSIONS Our results offer valuable insights into how the diverse backgrounds and specialties of EPs can influence the optimization of patient care in emergency settings. Understanding these patterns can help in the development of tailored training programs and protocols to enhance diagnostic accuracy and treatment efficacy in emergency cardiac care, ultimately optimizing patient treatment and improving outcomes.
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Affiliation(s)
- Manuel Sigle
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Wenke Faller
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Diana Heurich
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Monika Zdanyte
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Robert Wunderlich
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tuebingen, Tuebingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
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Yamada R, Horikoshi T, Nakamura T, Uematsu M, Yamaguchi K, Kobayahi T, Ando R, Yoshizaki T, Watanabe Y, Kuroki K, Nakamura K, Sato A. Pretransfer Aspirin Administration and Its Impact on Angiographic Outcomes for Patients with ST-Elevation Myocardial Infarction. Int Heart J 2024; 65:21-28. [PMID: 38296575 DOI: 10.1536/ihj.23-389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Although guidelines recommend early aspirin administration after diagnosis of ST-elevation myocardial infarction (STEMI), the decision of pretransfer aspirin administration is at the discretion of the primary physicians. Therefore, this study aimed to determine whether pretransfer aspirin administration was associated with better angiographical outcomes in patients with STEMI. This study compared the angiographic findings of thrombolysis in myocardial infarction (TIMI) flow grade in the infarct-related artery before percutaneous coronary intervention (PCI) between patients who received pretransfer aspirin and those who did not. In total, 28 patients (11.2%) were administered aspirin before transfer and 219 (88.8%) were administered aspirin upon arrival at the hospital. Propensity score matching yielded 135 patients [27 patients (20%) who were administered aspirin before transfer and 108 patients (80%) who were administered aspirin upon arrival at the hospital]. Patients who received pretransfer aspirin had a higher rate of TIMI-3 flow before PCI compared to those who did not receive pretransfer aspirin [8 (28.6%) versus 15 (6.8%), P < 0.01, in all study patients; 8 (26.6%) versus 7 (6.5%), P < 0.01, in propensity-score-matched patients]. Multivariable logistic regression analysis revealed that pretransfer aspirin administration was significantly associated with the presence of TIMI-3 flow before PCI, independent of age, gender, transfer time, and statin use (OR: 5.43, 95% CI: 1.94-15.2, P < 0.01, in all study patients; OR: 6.17, 95% CI: 1.86-20.46, P < 0.01, in propensity-score-matched patients). Pretransfer aspirin administration could lead to the early restoration of coronary blood flow in patients with STEMI, supporting its active use in STEMI care.
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Affiliation(s)
- Ryota Yamada
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
| | - Takeo Horikoshi
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
| | - Takamitsu Nakamura
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
| | - Manabu Uematsu
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
| | - Kazuyuki Yamaguchi
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
| | - Tsuyoshi Kobayahi
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
| | - Ryota Ando
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
| | - Toru Yoshizaki
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
| | - Yosuke Watanabe
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
| | - Kenji Kuroki
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
| | - Kazuto Nakamura
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
| | - Akira Sato
- Department of Cardiovascular Medicine, University of Yamanashi, Faculty of Medicine
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Navani RV, Dawson LP, Nehme E, Nehme Z, Bloom J, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Variation in Health Care Processes, Quality and Outcomes According to Day and Time of Chest Pain Presentation via Ambulance. Heart Lung Circ 2023:S1443-9506(23)00150-6. [PMID: 37100698 DOI: 10.1016/j.hlc.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/15/2023] [Accepted: 03/26/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Previous studies examining temporal variations in cardiovascular care have largely been limited to assessing weekend and after-hours effects. We aimed to determine whether more complex temporal variation patterns might exist in chest pain care. METHODS This was a population-based study of consecutive adult patients attended by emergency medical services (EMS) for non-traumatic chest pain without ST elevation in Victoria, Australia between 1 January 2015 and 30 June 2019. Multivariable models were used to assess whether time of day and week stratified into 168 hourly time periods was associated with care processes and outcomes. RESULTS There were 196,365 EMS chest pain attendances; mean age 62.4 years (standard deviation [SD] 18.3) and 51% females. Presentations demonstrated a diurnal pattern, a Monday-Sunday gradient (Monday peak) and a reverse weekend effect (lower rates on weekends). Five temporal patterns were observed for care quality and process measures, including a diurnal pattern (longer emergency department [ED] length of stay), an after-hours pattern (lower angiography or transfer for myocardial infarction, pre-hospital aspirin administration), a weekend effect (shorter ED clinician review, shorter EMS off-load time), an afternoon/evening peak period pattern (longer ED clinician review, longer EMS off-load time) and a Monday-Sunday gradient (ED clinician review, EMS offload time). Risk of 30-day mortality was associated with weekend presentation (Odds ratio [OR] 1.15, p=0.001) and morning presentation (OR 1.17, p<0.001) while risk of 30-day EMS reattendance was associated with peak period (OR 1.16, p<0.001) and weekend presentation (OR 1.07, p<0.001). CONCLUSIONS Chest pain care demonstrates complex temporal variation beyond the already established weekend and after-hours effect. Such relationships should be considered during resource allocation and quality improvement programs to improve care across all days and times of the week.
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Affiliation(s)
- Rohan V Navani
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia. http://www.twitter.com/RohanNavani
| | - Luke P Dawson
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Emily Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia
| | - Ziad Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; Department of Paramedicine, Monash University, Melbourne, Vic, Australia
| | - Jason Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; The Baker Institute, Melbourne, Vic, Australia
| | - Shelley Cox
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia
| | - David Anderson
- Ambulance Victoria, Melbourne, Vic, Australia; Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Vic, Australia
| | - Michael Stephenson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; Department of Paramedicine, Monash University, Melbourne, Vic, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Andrew J Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Department of Medicine, Monash University, Melbourne, Vic, Australia
| | - David Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; The Baker Institute, Melbourne, Vic, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; Department of Paramedicine, Monash University, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; The Baker Institute, Melbourne, Vic, Australia.
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Nakayama N, Yamamoto T, Kikuchi M, Hanada H, Mano T, Nakashima T, Hashiba K, Tanaka A, Matsuo K, Nomura O, Kojima S, Yamaguchi J, Matoba T, Tahara Y, Nonogi H. Prehospital Administration of Aspirin and Nitroglycerin for Patients With Suspected Acute Coronary Syndrome ― A Systematic Review ―. Circ Rep 2022; 4:449-457. [PMID: 36304434 PMCID: PMC9535127 DOI: 10.1253/circrep.cr-22-0060] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/23/2022] [Indexed: 12/11/2022] Open
Abstract
Background: Recent guidelines for acute coronary syndrome (ACS) recommend prehospital administration of aspirin and nitroglycerin for ACS patients. However, there is no clear evidence to support this. We investigated the benefits and harms of prehospital administration of aspirin and nitroglycerin by non-physician healthcare professionals in patients with suspected ACS. Methods and Results: We searched the PubMed database and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence. Three retrospective studies for aspirin and 1 for nitroglycerin administered in the prehospital setting to patients with acute myocardial infarction were included. Prehospital aspirin administration was associated with significantly lower 30-day and 1-year mortality compared with aspirin administration after arrival at hospital, with odds ratios (OR) of 0.59 (95% confidence interval [CI] 0.35–0.99) and 0.47 (95% CI 0.36–0.62), respectively. Prehospital nitroglycerin administration was also associated with significantly lower 30-day and 1-year mortality compared with no prehospital administration (OR 0.34 [95% CI 0.24–0.50] and 0.38 [95% CI 0.29–0.50], respectively). The certainty of evidence was very low in both systematic reviews. Conclusions: Our systematic reviews suggest that prehospital administration of aspirin and nitroglycerin by non-physician healthcare professionals is beneficial for patients with suspected ACS, although the certainty of evidence is very low. Further investigation is needed to determine the benefit of the prehospital administration of these agents.
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Affiliation(s)
- Naoki Nakayama
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Migaku Kikuchi
- Department of Cardiovascular Medicine, Emergency and Critical Care Center, Dokkyo Medical University
| | - Hiroyuki Hanada
- Department of Emergency and Disaster Medicine, Hirosaki University
| | | | - Takahiro Nakashima
- Department of Emergency Medicine and Michigan Center for Integrative Research in Critical Care, University of Michigan
| | | | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kunihiro Matsuo
- Department of Acute Care Medicine, Fukuoka University Chikushi Hospital
| | - Osamu Nomura
- Department of Emergency and Disaster Medicine, Hirosaki University
| | - Sunao Kojima
- Department of Internal Medicine, Sakurajyuji Yatsushiro Rehabilitation Hospital
| | | | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Faculty of Medical Sciences
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Ulrich Hansen M, Vejzovic V, Zdravkovic S, Axelsson M. Ambulance nurses' experiences of using prehospital guidelines for patients with acute chest pain - A qualitative study. Int Emerg Nurs 2022; 63:101195. [PMID: 35802956 DOI: 10.1016/j.ienj.2022.101195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/29/2022] [Accepted: 06/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ambulance nurses have an important role in early recognition and treatment often being the first medical contact for patients with acute chest pain. However, there is sparse knowledge on the experiences of ambulance nurses with regard to use of Prehospital Guidelines for patients with Acute Chest Pain. AIM To explore ambulance nurses' experiences of using prehospital guidelines for patients with acute coronary syndrome. METHOD A qualitative descriptive study design. Semi-structured interviews with 22 ambulance nurses recruited through purposive sampling strategy. The material was transcribed and analysed using content analysis. RESULTS Two main categories emerged from the results. The first category Sense of professional obligation included experiences of having an important role in caring for patients with acute chest pain. Understanding this role and the collaboration in the chain of care prompted ambulance nurses to adhere to the guidelines. However, not receiving enough feedback on the provided care made them uncertain whether to use guidelines. The second category Clinical difficulties using guidelines consisted of experiences of being surrounded by practical challenges while using guidelines. Ambulance nurses meet these challenges by relying on their clinical experience, which sometimes led to them deviating from the guidelines. CONCLUSIONS The ambulance nurses experienced a mixture of feeling secure and insecure when using the guidelines. Foremost, when encountering patients with unspecific chest pain, they felt a lack of feedback and an insufficient collaboration within the chain of care, which made them deviate from guidelines. To increase adherence in guidelines, post-registration education to update the knowledge and skills about guidelines for acute chest pain is needed followed by formal inter-disciplinary feedback on the care provided.
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Affiliation(s)
- Michael Ulrich Hansen
- Department of Care Science, Faculty of Health and Society, Malmö University, SE-205 06 Malmö, Sweden.
| | - Vedrana Vejzovic
- Department of Care Science, Faculty of Health and Society, Malmö University, SE-205 06 Malmö, Sweden
| | - Slobodan Zdravkovic
- Department of Care Science, Faculty of Health and Society, Malmö University, SE-205 06 Malmö, Sweden
| | - Malin Axelsson
- Department of Care Science, Faculty of Health and Society, Malmö University, SE-205 06 Malmö, Sweden
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6
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Guideline adherence among prehospital emergency nurses when caring for patients with chest pain: a prospective cohort study. Scand J Trauma Resusc Emerg Med 2021; 29:157. [PMID: 34717716 PMCID: PMC8557510 DOI: 10.1186/s13049-021-00972-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022] Open
Abstract
Background The emergency medical services (EMS) use guidelines to describe optimal patient care for a wide range of clinical conditions and symptoms. The intent is to guide personnel to provide patient care in line with best practice. The aim of this study is to describe adherence to such guidelines among prehospital emergency nurses (PENs) when caring for patients with chest pain.
Objective To describe guideline adherence among PENs when caring for patients with chest pain. To investigate whether guideline adherence is associated with patient age, sex or final diagnosis of acute myocardial infarction on hospital discharge. Methods Guideline adherence in terms of patient examination and pharmaceutical treatment was analysed in a cohort of 2092 EMS missions carried out in 2018 in Region Halland, Sweden. Multivariate regression was used to describe how guideline adherence is associated with patient age, sex and diagnosis on hospital discharge. Results Guideline adherence was high regarding examination of vital signs (93%) and electrocardiogram (ECG) registration (96%) but lower in terms of pharmaceutical treatment (ranging from 28 to 90%). Adherence was increased in cases in which the patient ended up with acute myocardial infarction (AMI) as diagnosis on discharge. Patients with AMI were given acetylsalicylic acid by PENs in 50% of cases. Women were less likely than men to receive treatment with acetylsalicylic acid and oxycodone. Conclusions Guideline adherence among PENs when caring for patients with chest pain is satisfactory in terms vital signs and ECG registration. Regarding pharmaceutical treatment guideline adherence is defective. Improved adherence is mainly associated with male sex in patients and a diagnosis of AMI on hospital discharge. Defective adherence excludes measures known to improve patients’ prognoses such as treatment with acetylsalicylic acid.
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Erste Hilfe. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00886-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Zideman DA, Singletary EM, Borra V, Cassan P, Cimpoesu CD, De Buck E, Djärv T, Handley AJ, Klaassen B, Meyran D, Oliver E, Poole K. European Resuscitation Council Guidelines 2021: First aid. Resuscitation 2021; 161:270-290. [PMID: 33773828 DOI: 10.1016/j.resuscitation.2021.02.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.
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Affiliation(s)
| | | | - Vere Borra
- Centre for Evidence-based Practice, Belgian Red Cross, Mechelen, Belgium; Cochrane First Aid, Mechelen, Belgium
| | - Pascal Cassan
- International Federation of Red Cross and Red Crescent, France
| | - Carmen D Cimpoesu
- University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Emergency Department and Prehospital EMS SMURD Iasi Emergency County Hospital "Sf. Spiridon" Iasi, Romania
| | - Emmy De Buck
- Centre for Evidence-based Practice, Belgian Red Cross, Mechelen, Belgium; Cochrane First Aid, Mechelen, Belgium; Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institute and Division of Acute and Reparative Medicine, Karolinska University Hospital, Sweden
| | | | - Barry Klaassen
- Emergency Medicine, Ninewells Hospital and Medical School Dundee, UK; British Red Cross, UK
| | - Daniel Meyran
- French Red Cross, Bataillon de Marins Pompiers de Marseille, France
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Pellegrino JL, Charlton NP, Carlson JN, Flores GE, Goolsby CA, Hoover AV, Kule A, Magid DJ, Orkin AM, Singletary EM, Slater TM, Swain JM. 2020 American Heart Association and American Red Cross Focused Update for First Aid. Circulation 2020; 142:e287-e303. [PMID: 33084370 DOI: 10.1161/cir.0000000000000900] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Djarv T, Swain JM, Chang WT, Zideman DA, Singletary E. Early or First Aid Administration Versus Late or In-hospital Administration of Aspirin for Non-traumatic Adult Chest Pain: A Systematic Review. Cureus 2020; 12:e6862. [PMID: 32181097 PMCID: PMC7053675 DOI: 10.7759/cureus.6862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Chest pain is a common symptom of acute coronary syndrome, including myocardial infarction (MI). Treatment with antiplatelet agents, such as aspirin, improves survival, although the ideal dose is uncertain. It is unknown if outcomes can be improved by giving aspirin early in the course of MI as part of the first-aid management as opposed to late or in-hospital administration. We searched the Medline, Embase, and Cochrane databases and used Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) for determining the certainty of evidence. We included studies in adults with non-traumatic chest pain, where aspirin was administered early (within two hours) following the onset of chest pain as part of first-aid management as compared with late or in-hospital administration (The International Prospective Register of Systematic Reviews (PROSPERO) registration number: CDR153316). From 1470 references, we included three studies (one randomized controlled trial (RCT) and two non-RCTs). Early administration (median 1.6 hours or pre-hospital) was associated with increased survival as compared with late administration (median 3.5 hours or in-hospital) at seven days; risk ratio (RR) 1.04 (95% CI 1.03-1.06), 30 days RR 1.05 (95% 1.02-1.07), and one-year RR 1.06 (95% CI1.03-1.10). The evidence is of very low certainty due to limitations in study design and the imprecision of the evidence. This systematic review would suggest that the early or first-aid administration of aspirin to adults with non-traumatic chest pain improves survival as compared with late or in-hospital administration.
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Affiliation(s)
- Therese Djarv
- Emergency Medicine, Karolinska Institute, Stockholm, SWE
| | - Janel M Swain
- Emergency Health Services, Nova Scotia, Dartmouth, CAN
| | - Wei-Tien Chang
- Emergency Medicine, National Taiwan University Hospital and College of Medicine, Taipei, TWN
| | - David A Zideman
- Pre-Hospital Emergency Medicine, Thames Valley Air Ambulance, Oxford, GBR
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Herrada L. ROL DEL SISTEMA PREHOSPITALARIO EN EL MANEJO DEL SINDROME CORONARIO. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Singletary EM, Zideman DA, De Buck EDJ, Chang WT, Jensen JL, Swain JM, Woodin JA, Blanchard IE, Herrington RA, Pellegrino JL, Hood NA, Lojero-Wheatley LF, Markenson DS, Yang HJ. Part 9: First Aid: 2015 International Consensus on First Aid Science With Treatment Recommendations. Circulation 2016; 132:S269-311. [PMID: 26472857 DOI: 10.1161/cir.0000000000000278] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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14
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Zideman D, De Buck E, Singletary E, Cassan P, Chalkias A, Evans T, Hafner C, Handley A, Meyran D, Schunder-Tatzber S, Vandekerckhove P. Erste Hilfe. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0093-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Strandmark R, Herlitz J, Axelsson C, Claesson A, Bremer A, Karlsson T, Jimenez-Herrera M, Ravn-Fischer A. Determinants of pre-hospital pharmacological intervention and its association with outcome in acute myocardial infarction. Scand J Trauma Resusc Emerg Med 2015; 23:105. [PMID: 26626732 PMCID: PMC4665872 DOI: 10.1186/s13049-015-0188-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 11/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was a) To identify predictors of the use of aspirin in the pre-hospital setting in acute myocardial infarction (AMI) and b) To analyze whether the use of any of the recommended medications was associated with outcome. METHODS All patients with a final diagnosis of AMI, transported by the Emergency Medical Services (EMS) and admitted to the coronary care unit at Sahlgrenska University Hospital in Gothenburg, Sweden, in 2009-2011, were included. RESULTS 1,726 patients were included. 58 % received aspirin by the EMS. Ischemic heart disease (IHD) was suspected in 84 %. Among patients who did not receive aspirin IHD was still suspected in 67 %. Among patients in whom IHD was suspected, and who were not on chronic treatment with aspirin the following predicted its pre-hospital use: a) age (odds ratio 0.98; 95 % confidence interval (CI) 0.96-0.99); b) a history of myocardial infarction (2.21; 1.21-4.04); c) priority given by EMS (8.07; 5.42-12.02); d) ST-elevation on ECG on admission to hospital (2.22; 1.50-3.29); e) oxygen saturation > 90 % (3.37; 1.81-6.27). After adjusting for confounders among patients who were not on chronic aspirin, only nitroglycerin of the recommended medications was associated with a reduced risk of death within 1 year (hazard ratio 0.40; 95 % CI 0.23-0.70). CONCLUSIONS Less than six out of ten patients with AMI received pre-hospital aspirin. Five clinical factors were independently associated with the pre-hospital administration of aspirin. This suggests that the decision to treat is multifactorial, and it highlights the lack of accurate diagnostic tools in the pre-hospital environment. Nitroglycerin was independently associated with a reduced risk of death, suggesting that we select the use for a low-risk cohort.
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Affiliation(s)
- Rasmus Strandmark
- Department of Metabolism and Cardiovascular Research, Institute of Internal Medicine, Sahlgrenska University Hospital, Johan Herlitz office, Registercentrum i Västra Götaland, 413 45, Gothenburg, Sweden.
| | - Johan Herlitz
- Department of Metabolism and Cardiovascular Research, Institute of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Christer Axelsson
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Andreas Claesson
- Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden.
| | - Anders Bremer
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Thomas Karlsson
- Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
| | | | - Annica Ravn-Fischer
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Blecker S, Gavin NP, Park H, Ladapo JA, Katz SD. Observation Units as Substitutes for Hospitalization or Home Discharge. Ann Emerg Med 2015; 67:706-713.e2. [PMID: 26619756 DOI: 10.1016/j.annemergmed.2015.10.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/24/2015] [Accepted: 10/21/2015] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Observation unit admissions have been increasing, a trend that will likely continue because of recent changes in reimbursement policies. The purpose of this study is to determine the effect of the availability of observation units on hospitalizations and discharges to home for emergency department (ED) patients. METHODS We studied ED visits with a final diagnosis of chest pain in the National Hospital Ambulatory Medical Care Survey from 2007 to 2010. ED visits that resulted in an observation unit admission were propensity-score matched to visits at hospitals without an observation unit. We used logistic regression to develop a prediction model for hospitalization versus discharge home for matched patients treated at nonobservation hospitals. The model was applied to matched observation unit patients to determine the likely alternative disposition had the observation unit not been available. RESULTS There were 1,325 eligible visits that represented 5,079,154 visits in the United States. Two hundred twenty-seven visits resulted in an observation unit admission. The predictive model for hospitalization had a c statistic of 0.91; variables significantly associated with subsequent hospitalization included age, history of coronary atherosclerosis, systolic blood pressure less than 115 beats/min, and administration of antianginal medications. When the model was applied to matched observation unit patients, 49.9% of them were categorized as discharge home likely. CONCLUSION In this study, we estimated that half of ED visits for chest pain that resulted in an observation unit admission were made by patients who may have been discharged home had the observation unit not been available. Increased availability of observation units may result in both decreased hospitalizations and decreased discharges to home.
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Affiliation(s)
- Saul Blecker
- Department of Population Health, NYU School of Medicine, New York, NY; Department of Medicine, NYU School of Medicine, New York, NY.
| | - Nicholas P Gavin
- Department of Emergency Medicine, NYU School of Medicine, New York, NY
| | - Hannah Park
- Department of Population Health, NYU School of Medicine, New York, NY
| | - Joseph A Ladapo
- Department of Population Health, NYU School of Medicine, New York, NY; Department of Medicine, NYU School of Medicine, New York, NY
| | - Stuart D Katz
- Department of Medicine, NYU School of Medicine, New York, NY
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Zideman DA, Singletary EM, De Buck EDJ, Chang WT, Jensen JL, Swain JM, Woodin JA, Blanchard IE, Herrington RA, Pellegrino JL, Hood NA, Lojero-Wheatley LF, Markenson DS, Yang HJ. Part 9: First aid: 2015 International Consensus on First Aid Science with Treatment Recommendations. Resuscitation 2015; 95:e225-61. [PMID: 26477426 DOI: 10.1016/j.resuscitation.2015.07.047] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlář A, Wyllie J, Zideman DA, Alfonzo A, Arntz HR, Askitopoulou H, Bellou A, Beygui F, Biarent D, Bingham R, Bierens JJ, Böttiger BW, Bossaert LL, Brattebø G, Brugger H, Bruinenberg J, Cariou A, Carli P, Cassan P, Castrén M, Chalkias AF, Conaghan P, Deakin CD, De Buck ED, Dunning J, De Vries W, Evans TR, Eich C, Gräsner JT, Greif R, Hafner CM, Handley AJ, Haywood KL, Hunyadi-Antičević S, Koster RW, Lippert A, Lockey DJ, Lockey AS, López-Herce J, Lott C, Maconochie IK, Mentzelopoulos SD, Meyran D, Monsieurs KG, Nikolaou NI, Nolan JP, Olasveengen T, Paal P, Pellis T, Perkins GD, Rajka T, Raffay VI, Ristagno G, Rodríguez-Núñez A, Roehr CC, Rüdiger M, Sandroni C, Schunder-Tatzber S, Singletary EM, Skrifvars MB, Smith GB, Smyth MA, Soar J, Thies KC, Trevisanuto D, Truhlář A, Vandekerckhove PG, de Voorde PV, Sunde K, Urlesberger B, Wenzel V, Wyllie J, Xanthos TT, Zideman DA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95:1-80. [PMID: 26477410 DOI: 10.1016/j.resuscitation.2015.07.038] [Citation(s) in RCA: 568] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Koenraad G Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland
| | - Ian K Maconochie
- Paediatric Emergency Medicine Department, Imperial College Healthcare NHS Trust and BRC Imperial NIHR, Imperial College, London, UK
| | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
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Zideman DA, De Buck ED, Singletary EM, Cassan P, Chalkias AF, Evans TR, Hafner CM, Handley AJ, Meyran D, Schunder-Tatzber S, Vandekerckhove PG. European Resuscitation Council Guidelines for Resuscitation 2015 Section 9. First aid. Resuscitation 2015; 95:278-87. [DOI: 10.1016/j.resuscitation.2015.07.031] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tataris KL, Mercer MP, Govindarajan P. Prehospital aspirin administration for acute coronary syndrome (ACS) in the USA: an EMS quality assessment using the NEMSIS 2011 database. Emerg Med J 2015; 32:876-81. [DOI: 10.1136/emermed-2014-204299] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/24/2015] [Indexed: 11/04/2022]
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Serebruany VL, Sibbing D, DiNicolantonio JJ. Dyspnea and reversibility of antiplatelet agents: ticagrelor, elinogrel, cangrelor, and beyond. Cardiology 2013; 127:20-4. [PMID: 24192670 DOI: 10.1159/000354876] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 07/17/2013] [Indexed: 02/02/2023]
Abstract
CONTEXT Oral reversible platelet P2Y12 receptor inhibitors (ticagrelor and elinogrel) cause double-digit rates of dyspnea, while irreversible oral antiplatelet drugs (aspirin, ticlopidoine, clopidogrel, and prasugrel) or intravenous glycoprotein IIb/IIIa inhibitors (abciximab, eptifibatide, or tirofiban) do not increase the incidence of dyspnea in randomized trials. Dyspnea after oral reversible antiplatelet agents remains unexplained. A transfusion-related acute lung injury (TRALI) hypothesis has been proposed. The dyspnea risks after cangrelor, an intravenous reversible antiplatelet agent, are not well defined but may offer a universal mechanism linking TRALI, dyspnea, and reversible platelet inhibition. OBJECTIVE We analyzed safety data from recent head-to-head randomized trials with reversible antiplatelet agents (ticagrelor, elinogrel, and cangrelor) compared to irreversible (clopidogrel/placebo) comparators. RESULTS All three reversible antiplatelet agents cause excess dyspnea. In contrast to the high double-digit rates after oral ticagrelor or elinogrel, the dyspnea risks after intravenous cangrelor were smaller (<2%) but still consistently and significantly higher than in the corresponding control arms. CONCLUSIONS The clinical utility of reversible antiplatelet strategies has been challenged. Despite a potential advantage of fewer bleeding events during heart surgery, reversible antiplatelet agents carry the risk of potential autoimmune reactions manifesting as dyspnea. Repeated binding and unbinding cycles, impaired platelet turnover, and lung sequestration or apoptosis of overloaded destructive platelets are among the potential mechanism(s) responsible for dyspnea after reversible antiplatelet agents.
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Affiliation(s)
- Victor L Serebruany
- HeartDrug™ Research Laboratories, Johns Hopkins University, Towson, Md., USA
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Barron T, Clawson J, Scott G, Patterson B, Shiner R, Robinson D, Wrigley F, Gummett J, Olola CHO. Aspirin administration by emergency medical dispatchers using a protocol-driven aspirin diagnostic and instruction tool. Emerg Med J 2012; 30:572-8. [DOI: 10.1136/emermed-2012-201339] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Walters DL, Cunningham C. Managing acute coronary syndromes in the prehospital and emergency setting: New guidelines from the Australian Resuscitation Council and New Zealand Resuscitation Council. Emerg Med Australas 2011; 23:240-3. [DOI: 10.1111/j.1742-6723.2011.01424.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bossaert L, O'Connor RE, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Hoek TLV, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e175-212. [PMID: 20959169 DOI: 10.1016/j.resuscitation.2010.09.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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O'Connor RE, Bossaert L, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Vanden Hoek TL, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S422-65. [PMID: 20956257 DOI: 10.1161/circulationaha.110.985549] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM, Hazinski MF, Lerner EB, Rea TD, Sayre MR, Swor RA. Part 5: Adult Basic Life Support. Circulation 2010; 122:S685-705. [PMID: 20956221 DOI: 10.1161/circulationaha.110.970939] [Citation(s) in RCA: 480] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Recent randomised studies suggest that experimental oral reversible platelet P2Y12 receptor inhibitor, AZD6140, causes dyspnoea. This also raises similar concerns about the parent compound, and another adenosine triphosphate (ATP) analogue (AR-69931MX or cangrelor), which is currently in Phase 3 trial in patients undergoing coronary interventions. We analysed package inserts, and available clinical trials safety data for antiplatelet agents with regard to the incidence of dyspnoea. We found that dyspnoea is a very rare complication of the presently approved platelet inhibitors, mostly caused by underlying disease, rather than antiplatelet therapy per se. The main reasons for respiratory distress after oral (AZD6140), and intravenous (cangrelor) agents may be the development of mild asymptomatic thrombotic thrombocytopenic purpura, fluid retention and dyspnoea because of the reversible nature of these drugs. Also, these agents are ATP analogues, which rapidly metabolise to adenosine, a well-known bronchoprovocator causing dyspnoea as well. In summary, dyspnoea is seldom considered, there are no treatment algorithms when it does occur, plausible mechanisms exist and despite these plausible mechanisms, the true cause of dyspnoea in these exposed individuals is unknown. Additional pulmonary function testing, immunological investigations and platelet receptor studies are urgently needed to determine the cause of dyspnoea after AZD6140, and to point out how such serious adverse reactions can be prevented, or at least minimised, raising potential concerns about this drug.
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Affiliation(s)
- V L Serebruany
- HeartDrug Research Laboratories, Johns Hopkins University, Towson, MD, USA.
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Hooker EA, Benoit T, Price TG. Reasons prehospital personnel do not administer aspirin to all patients complaining of chest pain. Prehosp Disaster Med 2006; 21:101-3. [PMID: 16771000 DOI: 10.1017/s1049023x00003435] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Aspirin is administered to patients with acute coronary syndromes (ACSs), but prehospital providers do not administer aspirin to all patients with chest pain that could be secondary to an ACS. OBJECTIVE To identify reasons prehospital providers fail to administer aspirin to all patients complaining of chest pain. METHODS A convenience sample of prehospital providers was surveyed as they transported patients with a chief complaint of chest pain to the emergency department. The providers were asked if they had given aspirin, nitroglycerin, or oxygen, or if they utilized a monitor. If the medications had not been administered, the paramedic was asked about the reason. The patient's age and previous cardiac history also was recorded. RESULTS A total of 52 patients with chest pain who were transported were identified over eight weeks, and all of the providers agreed to participate in the study. Only 13 of the patients (25%) received aspirin. Reasons given for not administering aspirin to the other 39 patients included: (1) chest pain was not felt to be cardiac in 13 patients (33%); (2) 10 patients already had taken aspirin that day (26%); (3) the medical provider was a basic-level emergency medical technician (EMT)-Basic and could not administer aspirin to six patients (15%); (4) pain subsided prior to arrival of emergency medical services (EMS) in these three patients; and (5) other reasons were provided for the remaining seven patients. CONCLUSIONS The most common reason that paramedics did not administer aspirin was the paramedic's belief that the chest pain was not of a cardiac nature. Another common reason for not giving aspirin was the inability of EMT-Basic providers to administer aspirin.
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Affiliation(s)
- Edmond A Hooker
- Department of Health Services Administration, Xavier University, 3800 Victory Parkway, Cincinnati, Ohio 45207-7331, USA.
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