Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial.

Importance: Although an emergency coronary angiogram (CAG) is recommended for patients who experience an out-of-hospital cardiac arrest (OHCA) with ST-segment elevation on the postresuscitation electrocardiogram (ECG), this strategy is still debated in patients without ST-segment elevation. Objective: To assess the 180-day survival rate with Cerebral Performance Category (CPC) 1 or 2 of patients who experience an OHCA without ST-segment elevation on ECG and undergo emergency CAG vs delayed CAG. Design, Setting, and Participants: The Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest (EMERGE) trial randomly assigned survivors of an OHCA without ST-segment elevation on ECG to either emergency or delayed (48 to 96 hours) CAG in 22 French centers. The trial took place from January 19, 2017, to November 23, 2020. Data were analyzed from November 24, 2020, to July 30, 2021. Main Outcomes and Measures: The primary outcome was the 180-day survival rate with CPC of 2 or less. The secondary end points were occurrence of shock, ventricular tachycardia, and/or fibrillation within 48 hours, change in left ventricular ejection fraction between baseline and 180 days, CPC scale at intensive care unit discharge and day 90, survival rate, and hospital length of stay. Results: A total of 279 patients (mean [SD] age, 64.7 [14.6] years; 195 men [69.9%]) were enrolled, with 141 (50.5%) in the emergency CAG group and 138 (49.5%) in the delayed CAG group. The study was underpowered. The mean (SD) time delay between randomization and CAG was 0.6 (3.7) hours in the emergency CAG group and 55.1 (37.2) hours in the delayed CAG group. The 180-day survival rates among patients with a CPC of 2 or less were 34.1% (47 of 141) in the emergency CAG group and 30.7% (42 of 138) in the delayed CAG group (hazard ratio [HR], 0.87; 95% CI, 0.65-1.15; P = .32). There was no difference in the overall survival rate at 180 days (emergency CAG, 36.2% [51 of 141] vs delayed CAG, 33.3% [46 of 138]; HR, 0.86; 95% CI, 0.64-1.15; P = .31) and in secondary outcomes between the 2 groups. Conclusions and Relevance: In this randomized clinical trial, for patients who experience an OHCA without ST-segment elevation on ECG, a strategy of emergency CAG was not better than a strategy of delayed CAG with respect to 180-day survival rate and minimal neurologic sequelae. Trial Registration: ClinicalTrials.gov Identifier: NCT02876458.

Effectiveness and Safety of P2Y12 Inhibitors Pretreatment in Primary Percutaneous Coronary Intervention with Long Transfer Times.

BACKGROUND: Early initiation of a new P2Y12 inhibitor in ST-elevation myocardial infarction (STEMI) patients prior to primary percutaneous coronary intervention (PCI) is recommended over clopidogrel. However, comparative data remain limited, especially in semi-rural regions with subsequent longer transfer times. OBJECTIVES: We aimed to assess the determinants, effectiveness, and safety of pretreatment with new P2Y12 inhibitors compared with clopidogrel in a primary PCI regional network. METHODS: Outcomes of 1235 primary PCI patients pretreated with new P2Y12 inhibitors (n = 1050) or clopidogrel (n = 185) were evaluated using a prospective registry. Primary effectiveness endpoint was the composite of death, recurrent myocardial infarction, stroke, or new revascularization. Serious bleedings were defined as Bleeding Academic Research Consortium ≥ 2. RESULTS: Clopidogrel was more likely to be used in older and female patients with more comorbidities. Mean transfer time was longer in the clopidogrel group (123.3 ± 67.3 vs. 102.3 ± 57.2 min; p < 0.01). The primary endpoint was less frequent with new P2Y12 inhibitors compared with clopidogrel (14.9 vs. 30.3%; odds ratio 0.58, 95% confidence interval [CI] 0.39-0.87; p < 0.01), mostly driven by a reduced rate of death (4.5 vs. 26% respectively; hazard ratio 0.25, 95% CI 0.16-0.38; p < 0.01). Bleeding rates did not differ between groups (1 vs. 0.5%, respectively; p = 0.96). CONCLUSION: Compared with clopidogrel, pretreatment with new P2Y12 inhibitors seems to be associated with lower risks of mortality and ischemic outcomes, and similar risks of bleeding in a real-world registry. Our results are in line with the guidelines recommending the preferential pre-PCI administration of new P2Y12 inhibitors in STEMI patients referred for primary PCI.

Impacts of chest compression cycle length and real-time feedback with a CPRmeter® on chest compression quality in out-of-hospital cardiac arrest: study protocol for a multicenter randomized controlled factorial plan trial.

BACKGROUND: With a survival rate of 6 to 11%, out-of-hospital cardiac arrest (OHCA) remains a healthcare challenge with room for improvement in morbidity and mortality. The guidelines emphasize the highest possible quality of cardiopulmonary resuscitation (CPR) and chest compressions (CC). It is essential to minimize CC interruptions, and therefore increase the chest compression fraction (CCF), as this is an independent factor for survival. Survival is significantly and positively correlated with the suitability of CCF targets, CC frequency, CC depth, and brief predefibrillation pause. CC guidance improves adherence to recommendations and allows closer alignment with the CC objectives. The possibility of improving CCF by lengthening the time between two CC relays and the effect of real-time feedback on the quality of the CC must be investigated. METHODS: Using a 2 × 2 factorial design in a multicenter randomized trial, two hypotheses will be tested simultaneously: (i) a 4-min relay rhythm improves the CCF (reducing the no-flow time) compared to the currently recommended 2-min relay rate, and (ii) a guiding tool improves the quality of CC. Primary outcomes (i) CCF and (ii) correct compression score will be recorded by a real-time feedback device. Five hundred adult nontraumatic OHCAs will be included over 2 years. Patients will be randomized in a 1:1:1:1 distribution receiving advanced CPR as follows: 2-min blind, 2 min with guidance, 4-min blind, or 4 min with guidance. Secondary outcomes are the depth, frequency, and release of CC; length (care, no-flow, and low-flow); rate of return of spontaneous circulation; characteristics of advanced CPR; survival at hospital admission; survival and neurological state on days 1 and 30 (or intensive care discharge); and dosage of neuron-specific enolase on days 1 and 3. DISCUSSION: This study will contribute to assessing the impact of real-time feedback on CC quality in practical conditions of OHCA resuscitation. It will also provide insight into the feasibility of extending the relay rhythm between two rescuers from the currently recommended 2 to 4 min. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03817892 . Registered on 28 January 2019.

EMERGEncy versus delayed coronary angiogram in survivors of out-of-hospital cardiac arrest with no obvious non-cardiac cause of arrest: Design of the EMERGE trial.

BACKGROUND: In adults, the most common cause of out-of-hospital cardiac arrests (OHCA) is acute coronary artery occlusion. If an immediate coronary angiogram (CAG) is recommended for survivors presenting a ST segment elevation on the electrocardiogram (ECG) performed after resuscitation, there is still a debate regarding the best strategy in patients without ST segment elevation. HYPOTHESIS: Performing an immediate CAG after an OHCA without ST segment elevation on the post-resuscitation ECG and no obvious non-cardiac cause of arrest could lead to a better 180-day survival rate with no or minimal neurological sequel as compared with a delayed CAG performed 48 to 96 hours after the arrest. DESIGN: The EMERGE trial is a prospective national, randomized, open and parallel group trial, in which 970 survivors of OHCA will be randomized (1:1) to either immediate (as soon as possible after return of spontaneous circulation) or delayed (48 to 96 h) CAG. Participants will be OHCA patients with no ST segment elevation on the post resuscitation ECG and no obvious non-cardiac cause of arrest. The primary endpoint of the study is the 180-day survival rate with no or minimal neurological sequel corresponding to Cerebral Performance Category (CPC) 1 or 2. The secondary endpoints are: occurrence of shock during the first 48 hours, ventricular tachycardia and/or fibrillation during the first 48 hours, change in left ventricular ejection fraction between baseline and 180 days assessed by echocardiogram, neurological status evaluated by the CPC score at intensive care unit (ICU) discharge and day 90 neurological status assessed by the Glasgow Outcome Scale Extended score (GOSE) at 90 and 180 days, overall survival rate, and hospital length of stay. SUMMARY: The EMERGE trial is a prospective, multicenter, randomized, controlled trial that will assess the 180-day survival rate with no or minimal neurologic sequel in patients resuscitated from an OHCA without ST segment elevation and who will be managed with either immediate or delayed CAG.

Prediction of myocardial infarction risk in older patients with acute coronary syndrome.

PURPOSES: To identify bedside variables that aid in diagnosis of acute coronary syndrome (ACS) and might facilitate rapid triage of patients aged > or = 65 years. BASIC PROCEDURES: Prospective, observational study of consecutive patients aged > or = 65 years with suspicion of ACS presenting to our emergency department (ED). Patients' medical characteristics were collected at baseline and during a 1-month follow-up period. We identified variables independently associated with ACS by multivariate analyses and bootstrapping techniques. MAIN FINDINGS: Among 399 patients, 124 (31.1%) received a diagnosis of ACS (61 acute myocardial infarction, 63 unstable angina). We surveyed multiple clinical and ECG variables to develop a predictive model which included the following variables: male sex, history of coronary artery disease, typical chest pain, dyspnea, epigastric pain, pathological Q-wave, ST-segment elevation (area under the receiver operating characteristic curve (AUC) 0.79, 95% confidence interval 0.71 to 0.82). With the addition of cardiac troponin I to the model the AUC increased to 0.83 (0.79 to 0.88). We used these findings to create the Heart Attack Risk for aged Patient (HARP) scale. Our data suggest that patients with a low HARP score might be safely managed without further testing. PRINCIPAL CONCLUSIONS: A model based on variables easily available at ED presentation from history, physical examination, and electrocardiography, can help ED physicians to identify seniors at very low risk of ACS.

Association between timing of intensive care unit admission and outcomes for emergency department patients with community-acquired pneumonia.

OBJECTIVE: To compare the 28-day mortality and hospital length of stay of patients with community-acquired pneumonia who were transferred to an intensive care unit on the same day of emergency department presentation (direct-transfer patients) with those subsequently transferred within 3 days of presentation (delayed-transfer patients). DESIGN: Secondary analysis of the original data from two North American and two European prospective, multicenter, cohort studies of adult patients with community-acquired pneumonia. PATIENTS: In all, 453 non-institutionalized patients transferred within 3 days of emergency department presentation to an intensive care unit were included in the analysis. Supplementary analysis was restricted to patients without an obvious indication for immediate transfer to an intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The sample consisted of 138 delayed-transfer and 315 direct-transfer patients, among whom 150 (33.1%) were considered to have an obvious indication for immediate intensive care unit admission. After adjusting for the quintile of propensity score, delayed intensive care unit transfer was associated with an increased odds ratio for 28-day mortality (2.07; 95% confidence interval, 1.12-3.85) and a decreased odds ratio for discharge from hospital for survivors (0.53; 95% confidence interval, 0.39-0.71). In a propensity-matched analysis, delayed-transfer patients had a higher 28-day mortality rate (23.4% vs. 11.7%; p = 0.02) and a longer median hospital length of stay (13 days vs. 7 days; p < .001) than direct-transfer patients. Similar results were found after excluding the 150 patients with an obvious indication for immediate intensive care unit admission. CONCLUSIONS: Our findings suggest that some patients without major criteria for severe community-acquired pneumonia, according to the recent Infectious Diseases Society of America/American Thoracic Society consensus guideline, may benefit from direct transfer to the intensive care unit. Further studies are needed to prospectively identify patients who may benefit from direct intensive care unit admission despite a lack of major severity criteria for community-acquired pneumonia based on the current guidelines.

Risk stratification of early admission to the intensive care unit of patients with no major criteria of severe community-acquired pneumonia: development of an international prediction rule.

INTRODUCTION: To identify risk factors for early (< three days) intensive care unit (ICU) admission of patients hospitalised with community-acquired pneumonia (CAP) and not requiring immediate ICU admission, and to stratify the risk of ICU admission on days 1 to 3. METHODS: Using the original data from four North American and European prospective multicentre cohort studies of patients with CAP, we derived and validated a prediction rule for ICU admission on days 1 to 3 of emergency department (ED) presentation, for patients presenting with no obvious reason for immediate ICU admission (not requiring immediate respiratory or circulatory support). RESULTS: A total of 6560 patients were included (4593 and 1967 in the derivation and validation cohort, respectively), 303 (4.6%) of whom were admitted to an ICU on days 1 to 3. The Risk of Early Admission to ICU index (REA-ICU index) comprised 11 criteria independently associated with ICU admission: male gender, age younger than 80 years, comorbid conditions, respiratory rate of 30 breaths/minute or higher, heart rate of 125 beats/minute or higher, multilobar infiltrate or pleural effusion, white blood cell count less than 3 or 20 G/L or above, hypoxaemia (oxygen saturation < 90% or arterial partial pressure of oxygen (PaO2) < 60 mmHg), blood urea nitrogen of 11 mmol/L or higher, pH less than 7.35 and sodium less than 130 mEq/L. The REA-ICU index stratified patients into four risk classes with a risk of ICU admission on days 1 to 3 ranging from 0.7 to 31%. The area under the curve was 0.81 (95% confidence interval (CI) = 0.78 to 0.83) in the overall population. CONCLUSIONS: The REA-ICU index accurately stratifies the risk of ICU admission on days 1 to 3 for patients presenting to the ED with CAP and no obvious indication for immediate ICU admission and therefore may assist orientation decisions.

Impact of point-of-care testing in the emergency department evaluation and treatment of patients with suspected acute coronary syndromes.

OBJECTIVES: To assess the impact of point-of-care testing (POCT) for troponin I (cTnI) measurement on the time to anti-ischemic therapy (TAIT) for patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) presenting to the emergency department (ED). METHODS: This was an open-label, randomized, single-center trial conducted in a university-affiliated hospital. cTnI measurement of patients with suspicion of NSTE-ACS coming to the ED was randomly allocated to POCT or central hospital laboratory testing (CHLT). The authors compared patients' baseline characteristics, time to anti-ischemic therapy, and medical outcomes between the randomized groups, in all study participants and in high-risk NSTE-ACS (cTnI level >or= 0.10 microg/mL), and in those with low suspicion ACS (no chest pain and no ST deviation). RESULTS: Of the 860 patients enrolled, 113 were high-risk NSTE-ACS patients, including 53 (46.9%) allocated to POCT and 60 (53.1%) to CHLT. POCT was associated with decreased time to anti-ischemic therapy of about three-quarters of an hour, which was due to a shorter time to physician notification of cTnI level, in both all and subgroup participants. In contrast, neither ED length of stay nor medical outcomes differed between study groups. CONCLUSIONS: Point-of-care testing for cTnI measurement might be clinically relevant for ED patients with a suspicion of NSTE-ACS, particularly for high-risk patients with a low suspicion of ACS.

A single procalcitonin level does not predict adverse outcomes of women with pyelonephritis.

OBJECTIVES: Predicting medical outcomes for pyelonephritis in women is difficult, leading to unnecessary hospitalization. Unlike other serious infectious diseases, high procalcitonin (PCT) level has never been associated with 28-d adverse medical outcomes in women with pyelonephritis. Therefore, we sought to determine the accuracy of PCT in discriminating between pyelonephritis with adverse medical outcome (PAMO) and pyelonephritis without adverse medical outcome (PWAMO). PATIENTS AND METHODS: Adult women with pyelonephritis presenting to the emergency department of a French tertiary care hospital were consecutively included. Those patients who developed adverse medical outcomes during a 28-d follow-up period were identified as having PAMO. Baseline characteristics and PCT level were compared between patients with PAMO and PWAMO. RESULTS: Eleven women (19.0%) had PAMO and 47 (81%) had PWAMO. The median PCT level was higher in PAMO compared with PWAMO 0.51 ng/ml (IQR: 0.04-3.8) and 0.08 ng/ml (IQR: 0.01-1.0), but this difference was not statistically significant (p=0.07). We failed to find a threshold value for PCT that discriminated between PAMO and PWAMO (ROC, AUC=0.67 [95%CI, 0.51-0.86]). All but one subject with PAMO had either a PCT level >0.1 ng/ml or an underlying genitourinary abnormality by radiographic testing. CONCLUSIONS: A single PCT level was a poor predictor of 28-d adverse medical outcomes in women with pyelonephritis treated in the emergency department. Prediction based on underlying genitourinary abnormality by radiographic testing in addition to the PCT level should be investigated in future studies.

Routine use of the Pneumonia Severity Index for guiding the site-of-treatment decision of patients with pneumonia in the emergency department: a multicenter, prospective, observational, controlled cohort study.

BACKGROUND: Although the Pneumonia Severity Index (PSI) has been extensively validated, little is known of the impact of its routine use as an aid to site-of-treatment decisions for patients with pneumonia who present to emergency departments (EDs). METHODS: A prospective, observational, controlled cohort study of patients with pneumonia was conducted in 8 EDs that used the PSI (PSI-user EDs) and 8 EDs that did not use the PSI (PSI-nonuser EDs) in France. The outcomes examined included the proportion of "low-risk" patients (PSI risk classes I-III) treated as outpatients, all-cause 28-day mortality, admission of inpatients to the intensive care unit, and subsequent hospitalization of outpatients. RESULTS: Of the 925 patients enrolled in the study, 472 (51.0%) were treated at PSI-user EDs, and 453 (49.0%) were treated at PSI-nonuser EDs; 449 (48.5%) of all patients were considered to be at low risk. In PSI-user EDs, 92 (42.8%) of 215 patients at low risk were treated as outpatients, compared with 56 (23.9%) of 234 patients at low risk in PSI-nonuser EDs. The adjusted odds ratios for outpatient treatment were higher for patients in PSI risk classes I and II who were treated in PSI-user EDs, compared with PSI-nonuser EDs (adjusted odds ratio, 7.0 [95% confidence interval, 2.0-25.0] and 4.6 [95% confidence interval, 1.3-16.2], respectively), whereas the adjusted odds ratio did not differ by PSI-user status among patients in risk class III or among patients at high risk. After adjusting for pneumonia severity, mortality was lower in patients who were treated in PSI-user EDs; other safety outcomes did not differ between patients treated in PSI-user and PSI-nonuser EDs. CONCLUSIONS: The routine use of the PSI was associated with a larger proportion of patients in PSI risk classes I and II who had pneumonia and who were treated in the outpatient environment without compromising their safety.