Coronary atherosclerosis and adverse outcomes in patients with recent-onset atrial fibrillation and troponin rise.

BACKGROUND: The relationship between troponin and atrial fibrillation (AF) without acute coronary syndrome is still unclear. We sought to investigate the presence of coronary atherosclerosis and adverse outcomes in patients with AF. METHODS: Consecutive patients with recent-onset AF and without severe comorbidities were enrolled between 2004 and 2013. Patients with a troponin rise or with adverse outcomes were considered for coronary angiography and revascularization when "critical" stenosis (≥70%) was recognized. Propensity score matching was performed to adjust for baseline characteristics; after matching, no differences existed between the groups of patients with or without troponin rise. The primary end point was the composite of acute coronary syndrome, revascularization, and cardiac death at 1- and 12-month follow-ups. RESULTS: Of 3627 patients enrolled, 3541 completed the study; 202 (6%) showed troponin rise; and 91 (3%), an adverse outcome. In the entire cohort, on multivariate analysis, the odds ratio for the occurrence of the primary end point of troponin rise was 14 (95% confidence interval [CI], 10-23; P<.001), and that of known coronary artery disease was 3 (CI, 2-5; P=.001). In the matching cohort, the odds ratio of troponin rise was 10 (CI, 4-22; P<.001), and that of TIMI score greater than 2 was 4 (CI, 2-9; P≤.001). In the entire cohort, patients with or without troponin rise achieved the primary end point in 38 (19%) and 43 (1%) patients, respectively (P<.001). Stroke occurred in 4 (2%) and 20 (1%), respectively (P=.018). Critical stenosis and revascularization account for 23 (12%) and 15 (1%), respectively (P<.001). In the matching cohort, results were confirmed, but incidence of stroke was comparable. CONCLUSIONS: Patients with recent-onset AF and troponin rise showed higher prevalence of coronary atherosclerosis and adverse cardiac events. Stroke per se did not succeed in justifying the high morbidity. Thus, beyond stroke, coronary atherosclerosis might have a pivotal role in poor outcomes.

Comparison of exercise electrocardiogram and exercise echocardiography in intermediate-risk chest pain patients.

BACKGROUND: The novel exercise computer-assisted high-frequency QRS analysis (HF/QRS) has demonstrated improved sensitivity and specificity over the conventional ST/electrocardiogram-segment analysis (ST/ECG) in the detection of myocardial ischemia. The aim of the present study was to compare the diagnostic value of the validated exercise echocardiography (ex-Echo) with the novel exercise ECG (ex-ECG) including HF/QRS and ST/ECG analysis. METHODS: A prospective cohort study was conducted in the emergency department of a tertiary care teaching Hospital. Patients with chest pain (CP), normal resting ECGs, troponins, and echocardiography, labeled as "intermediate-risk" for adverse coronary events, underwent the novel ex-ECG and ex-Echo. An ST-segment depression of at least 2 mV or at least 1 mV when associated with CP was considered as an index of ischemia, as well as a decrease of at least 50% in HF/QRS intensity, or new wall motion abnormalities on ex-Echo. Exclusion criteria were QRS duration of at least 120 milliseconds, poor echo-acoustic window, and inability to exercise. Patients were followed up to 3 months. The end point was the composite of coronary stenoses of 50% or greater at angiography or acute coronary syndrome, revascularization, and cardiovascular death on the 3-month follow-up. RESULTS: Of 188 patients enrolled, 18 achieved the end point. The novel ex-ECG and ex-Echo showed comparable negative predictive value (97% vs 96%; P = .930); however, sensitivity was 83% vs 61%, respectively (P = .612), and specificity was 64% vs 92%, respectively,(P = .026). The areas on receiver operating characteristic analysis were comparable (ex-ECG: 0.734 [95% confidence interval, or CI, 0.62-0.85] vs ex-Echo: 0.767 [CI, 0.63-0.91]; C statistic, P = .167). On multivariate analysis, both ex-ECG (hazard ratio, 5; CI, 1-20; P = .017) and ex-Echo (HR, 12; CI, 4-40; P < .001) were predictors of the end point. CONCLUSIONS: In intermediate-risk CP patients, the novel ex-ECG including HF/QRS added to ST/ECG analysis was a valuable diagnostic tool and might be proposed to avoid additional imaging. However, the novel test needs additional study before it can be recommended as a replacement for current techniques.

Primary Health Care and Disasters: Applying a "Whole-of-Health System" Approach through Reverse Triage in Mass-Casualty Management.

INTRODUCTION: In 2019, the World Health Organization (WHO) published the Health Emergency and Disaster Risk Management (H-EDRM) framework detailing how effective management of disasters, including mass-casualty incidents (MCIs), can be achieved through a whole-of-health system approach where each level of the health care system is involved in all phases of the disaster cycle. In light of this, a primary health care (PHC) approach can contribute to reducing negative health outcomes of disasters, since it encompasses the critical roles that primary care services can play during crises. Hospitals can divert non-severe MCI victims to primary care services by applying reverse triage (RT), thereby preventing hospital overloading and ensuring continuity of care for those who do not require hospital services during the incident. STUDY OBJECTIVE: This study explores the topic by reviewing the literature published on early discharge of MCI victims through RT criteria and existing referral pathways to primary care services. METHODS: A scoping literature review was performed and a total of ten studies were analyzed. RESULTS: The results showed that integrating primary care facilities into disaster management (DM) through the use of RT may be an effective strategy to create surge during MCIs, provided that clear referral protocols exist between hospitals and primary care services to ensure continuity of care. Furthermore, adequate training should be provided to primary care professionals to be prepared and be able to provide quality care to MCI victims. CONCLUSION: The results of this current review can serve as groundwork upon which to design further research studies or to help devise strategies and policies for the integration of PHC in MCI management.

Severity of respiratory failure and outcome of patients needing a ventilatory support in the Emergency Department during Italian novel coronavirus SARS-CoV2 outbreak: Preliminary data on the role of Helmet CPAP and Non-Invasive Positive Pressure Ventilation.

BACKGROUND: Novel Coronavirus SARS-CoV-2 pandemic is spreading around the world. At the end of February, the outburst of the pandemic has hit hard on northern Italian's hospitals. As of today, no data have been published regarding the severity of respiratory failure of patients presenting to the Emergency Departments. Moreover, the outcome the patients forced to undergo Continuous Positive Airway Pressure (CPAP) or Non-Invasive Positive Pressure Ventilation (NIPPV) due to lack of Intensive Care resources is unknown. "Papa Giovanni XXIII" hospital (HPG23) of Bergamo is one of the largest hospitals in the Country, with an Emergency Department (ED) managing over 100,000 patients per year. METHODS: This is a retrospective observational study based on chart review of patients presenting to the Emergency Department of HPG23 from 29/02/2020 to 10/03/2020 with a clinical condition highly suspicious for COVID-19 infection. Registration of admission rates, severity of respiratory failure (ARDS classification), need of respiratory support, SARS-CoV-2 PCR test and outcome of patients treated with a ventilatory support were registered on 10th of May 2020. FINDINGS: From 29/02 to 10/03 611 patients with a suspected diagnosis of COVID-19 infection were evaluated in our ED; 320 (52%) met the criteria for hospital admission and 99 (31%) needed to be immediately started on ventilatory support (81% CPAP, 7% NIPPV, 12% Invasive Mechanical Ventilation). Eighty-five (86%) of the 99 patients needing a ventilatory support eventually had SARS-CoV-2 infection confirmed by PCR test on nasal-pharyngeal swab. Their median PO2/FiO2 ratio was 128 (IQR 85-168), with 23 patients (29.5%) classified as severe ARDS. Mortality rate as of 10th of May was 76.5%, ranging from 44.4% within patients <60 years old to 85% within those older than 60 years (p = 0.001). NIPPV/CPAP failure occurred in 91.5% of patients. INTERPRETATION: The population of patients suspected for COVID-19 infection presenting at our ED showed a very high rate of severe respiratory failure, with urgent need of a large amount of intensive care resources. Mortality rates of critically ill patients with confirmed COVID-19 (76.5%) are similar to previously reported studies with similar population. CPAP/NIPPV could be a valid strategy to treat severely hypoxic patients that cannot be intubated in the ED due to lack of intensive care resources. FUNDING: No funds were received for this research project.

Teamwork evaluation during emergency medicine residents' high-fidelity simulation.

Background: Teamwork training has been included in several emergency medicine (EM) curricula; the aim of this study was to compare different scales' performance in teamwork evaluation during simulation for EM residents. Methods: In the period October 2013-June 2014, we performed bimonthly high-fidelity simulation sessions, with novice (I-III year, group 1 (G1)) and senior (IV-V year, group 2 (G2)) EM residents; scenarios were designed to simulate management of critical patients. Videos were assessed by three independent raters with the following scales: Emergency Team Dynamics (ETD), Clinical Teamwork Scale (CTS) and Team Emergency Assessment Measure (TEAM). In the period March-June, after each scenario, participants completed the CTS and ETD. Results: The analysis based on 18 sessions showed good internal consistency and good to fair inter-rater reliability for the three scales (TEAM, CTS, ETD: Cronbach's α 0.954, 0.954, 0.921; Intraclass Correlation Coefficients (ICC), 0.921, 0.917, 0.608). Single CTS items achieved highly significant ICC results, with 12 of the total 13 comparisons achieving ICC results ≥0.70; a similar result was confirmed for 4 of the total 11 TEAM items and 1 of the 8 total ETD items. Spearman's r was 0.585 between ETD and CTS, 0.694 between ETD and TEAM, and 0.634 between TEAM and CTS (scales converted to percentages, all p<0.0001). Participants gave themselves a better evaluation compared with external raters (CTS: 101±9 vs 90±9; ETD: 25±3 vs 20±5, all p<0.0001). Conclusions: All examined scales demonstrated good internal consistency, with a slightly better inter-rater reliability for CTS compared with the other tools.

A simplified way for the urgent treatment of somatic pain in patients admitted to the emergency room: the SUPER algorithm.

Somatic pain is one of the most frequent symptoms reported by patients presenting to the emergency department (ED), but, in spite of this, it is very often underestimated and under-treated. Moreover, pain-killers prescriptions are usually related to the medical examination, leading to a delay in its administration, thus worsening the patient's quality of life. With our study, we want to define and validate a systematic and homogeneous approach to analgesic drugs administration, testing a new therapeutic algorithm in terms of earliness, safety, and efficacy. 442 consecutive patients who accessed our ED for any kind of somatic pain were enrolled, and then randomly divided into two groups: group A follow the normal process of access to pain-control drugs, and group B follow our SUPER algorithm for early administration of drugs to relieve pain directly from triage. We excluded from the study, patients with abdominal pain referred to the surgeon, patients with headache, recent history of trauma, history of drug allergies, and life-threatening conditions or lack of cooperation. Drugs used in the study were those available in our ED, such as paracetamol, paracetamol/codeine, ketorolac-tromethamine, and tramadol-hydrochloride. Pain level, risk factors, indication, and contraindication of each drug were taken into account in our SUPER algorithm for a rapid and safe administration of it. The Verbal Numeric Scale (VNS) and the Visual Analog Scale (VAS) were used to verify the patient's health and perception of it. Only 59 patient from group A (27.1 %) received analgesic therapy (at the time of the medical examination) compared to 181 patients (100 %) of group B (p < 0.001). Group B patients, received analgesic therapy 76 min before group A subjects (p < 0.01), resulting in a significant lower VNS (7.31 ± 1.68 vs 4.75 ± 2.3; p < 0.001), and a superior VAS after discharge (54.43 ± 22.16 vs 61.30 ± 19.13; p < 0.001) compared to group A subjects. No significant differences concerning side effects were observed between group A and group B patients. Early administration of a pain-control therapy directly from triage is safe and effective, and significantly improves patients perceptions of their own health.

High-frequency QRS analysis compared to conventional ST-segment analysis in patients with chest pain and normal ECG referred for exercise tolerance test.

BACKGROUND: The novel analysis of high-frequency QRS components (HFQRS-analysis) has been proposed in patients with chest pain (CP) and normal electrocardiography (ECG) referred for exercise tolerance test (ex-ECG). The aim of the study was to compare the diagnostic value of ex-ECG with ex-HFQRS-analysis. METHODS: Patients with CP and normal ECG, troponin, and echocardiography were considered. All patients underwent ex-ECG for conventional ST-segment-analysis and ex-HFQRS-analysis. A decrease ≥ 50% of the HFQRS signal intensity recorded in at least 2 contiguous leads was considered an index of ischemia, as ST-segment depression ≥ 2 mm or ≥ 1 mm and CP on ex-ECG. Exclusion criteria were: QRS duration ≥ 120 ms and inability to exercise. End-point: The composite of coronary stenosis ≥ 70% or acute coronary syndrome, revascularization, cardiovascular death at 3-month follow-up. RESULTS: Three-hundred thirty-seven patients were enrolled (age 60 ± 15 years). The percent-age of age-adjusted maximal predicted heart rate was 89 ± 10 beat per minute and the maximal systolic blood pressure was 169 ± 23 mm Hg. Nineteen patients achieved the end-point. In multivariate analysis, both ex-ECG and ex-HFQRS were predictors of the end-point. The ex-HFQRS-analysis showed higher sensitivity (63% vs. 26%; p < 0.05), lower specificity (68% vs. 95%; p < 0.001), and comparable negative predictive value (97% vs. 96%; p = 0.502) when compared to ex-ECG-analysis. Receiver operator characteristics analysis showed the incremental diagnostic value of HFQRS (area: 0.655, 95% CI 0.60-0.71) over conventional ex-ECG (0.608, CI 0.55-0.66) and CP score (0.530, CI 0.48-0.59), however without statistical significance in pairwise comparison by C-statistic. CONCLUSIONS: In patients with CP submitted to ex-ECG, the novel ex-HFQRS-analysis shows a valuable incremental diagnostic value over ST-segment-analysis.

Hypertension and atrial fibrillation: prognostic aspects of troponin elevations in clinical practice.

BACKGROUND: Hypertension and atrial fibrillation (AFib) frequently coexist in clinical practice. However, it is unclear whether this association per se or in combination with coronary artery disease (CAD) is a predictor of adverse outcomes. AIM: The aim of this study is to recognize and treat CAD in patients with hypertension and AFib. METHODS: Patients with long-standing hypertension and recent-onset AFib (lasting ≤48 hours) were enrolled and managed with standard care regardless of the presence of troponin elevations (e-TnI) (group 1, n=636, 2010-2011 years) or managed with tailored-care including echocardiography and stress testing when presenting with e-TnI (group 2, n=663, 2012-2013 years). ENDPOINT: The composite of ischemic vascular events including stroke, acute coronary syndrome, revascularization, and death at the 6-month follow-up. RESULTS: Out of 1299 patients enrolled, those with e-TnI (56 and 57 in groups 2 and 1, respectively, P=0.768) were more likely to admit in group 2 vs. group 1 (21 vs. 32, respectively, P=0.060), and less likely to undergo stress testing in group 2 vs. group 1 (15 vs. 1, respectively, P<0.001). Twenty-one patients in group 2 were admitted with positive stress testing (n=9) or high e-TnI (n=12; 1.04±1.98 ng/mL); conversely 35 were discharged with negative stress testing (n=6) or very-low e-TnI (n=29; 0.27±0.22 ng/mL). Finally, 7 patients vs. 1, in groups 2 and 1, respectively, underwent revascularization (P=0.032), and 3 vs. 12 reached the endpoint (P=0.024). On multivariate analysis, e-TnI, known CAD and age were predictors of the endpoint. CONCLUSIONS: In patients with hypertension, AFib, and e-TnI, tailored-care inclusive of echocardiography and stress testing succeeded in recognizing and treating CAD avoiding adverse events without increase in admissions.