Evaluation of anticoagulation therapy in non-valvular atrial Fibrillation in the emergency department.

INTRODUCTION: The vitamin K antagonists (VKAs) are currently the most effective therapeutic class for the prevention of cerebrovascular eventsin atrial fibrillation (AF) patients. However, several studies showed an under-prescription of this therapy.The aim of the study was to assess the prescription of VKAs in non-valvular AF (NVAF) patients and factors influencing the non-prescription ofsuch treatment. METHODS: We conducted a prospective, observational study in an emergency department (ED). Patients with high thromboembolic risk NVAFand not receiving VKAs beforehand were included. Calculation of CHA2DS2-VASc and HAS-BLED scores was performed. An analytic study wasconducted in order to identify independent predictors of the under-prescription of VKAs. RESULTS: During study, 176 patients were enrolled, the mean age was 67±13 years and 66% were women. The mean CHA2DS2VASc andHASBLED scores were 2.88 ± 1.55 and 1.52 ± 1.05, respectively. Among our cohort, VKA was prescribed in 36% of cases. Age >70 years(OR=1.59, 95%CI[1.11-2.21],p<0.001), creatinine level ≥110 µmol/l (OR=2.54,95%CI[1.20-5.37],p=0.01) and aspirin use (OR =1.7,95%CI [1.08-2.67],p=0.02) were independently associated with under-prescription of VKAs. Bedside, the main causes reported by the emergency physicians(EP) were: factors related to patient characteristics (n=38,34%), factors related to emergency physician (n=62,55%), factors related to the patientenvironment (n=20,17%) and factors related to the drug (n=22,23%). CONCLUSIONS: Our results showed that the prescription of VKAs was low in ED. The reasons of VKA under-prescription are linked usually toseveral factors inherent to patient and to the adherence of EP to new recommendations.

[Evaluation of fibrinolysis with streptokinase in ST-elevation myocardial infarction admitted to emergency department]. / Evaluation de la fibrinolyse par la streptokinase dans l'infarctus du myocarde avec sus décalage du segment ST admis aux urgences.

BACKGROUND: Fibrinolysis during ST elevation myocardial infarction (STEMI) is feasible in the emergency departments (ED), and this reduces the delay from first medical contact to coronary reperfusion. The aim of the study is to: 1) Evaluate fibrinolysis with streptokinase (SK) in STEMI admitted to the ED. 2) identify clinical criteria predictive of fibrinolysis success. METHODS: prospective study (July 2008-March 2012). Inclusion of STEMI thrombolysed by SK. Fibrinolysis success was defined according to clinical and Electrocardiogram criteria. Multivariate study is used to identify the factors associated with thrombolysis success. RESULTS: Out of the 329 STEMI enrolled during the study period, 224 (68%) were thrombolysed. Mean age = 57 ± 11 years (20-86 years) sex ratio = 6. The average time chest pain - emergency admission was 195 ± 177 min (15 min to 12 hours). The 2/3 of patients had consulted during the first 3 hours. The average success rate of thrombolysis was 59% and reached 83% the first hour, 66% the second hour and 58.7% the third hour. In multivariate analysis, the three independent predictors factors of a fibrinolysis success were: active smoking, current treatment with beta blockers and the delay from onset chest pain to the ED visit less than 180 min. Conversely, diabetes was associated with fibrinolysis failure. Fibrinolysis got complicated by two intracerebral hemorrhages. Three patients had died in the ED. CONCLUSION: Two thirds of patients with STEMI have consulted 3 h after onset of chest pain. Fibrinolysis with streptokinase was effective in 59% of cases.