CV (March 2016)
Research: One hour Trop I ROMI. Am J EM 2015
Research: Walkey et al. Outcomes AFib Tx in Sepsis. Chest 2016
AIR: Cardiology
Research: One hour Trop I ROMI. Am J EM 2015
Research: Walkey et al. Outcomes AFib Tx in Sepsis. Chest 2016
AIR: Cardiology
11 comments
One hour trop ROMI
What are some strengths of the study?
– Multicenter international study. Derived in 900 patients and then validated in another 900. Seem like good numbers.
What are the limitations?
– Excluded patients that didn’t get a 1 hour second troponin drawn, which often seemed to be because patients were too sick or were already out of the department. I suppose this eliminates a lot of the sicker patients from the study but that’s not who we’re gearing the 1 hour rule out towards anyway, so probably doesn’t matter too much.
What are the main outcomes of the study?
– Surprisingly tough to find “primary outcome” but think it was 30 day mortality between “ruled out” and “ruled in” groups
Does reading this article change your practice? If so, how?
– I’m more likely to get shorter delta troponins on patients on both ends of the “sick” spectrum. If I’m worried about them based on story and the first EKG and trop aren’t impressive, I’m more likely now to get a 1 or 2 hour troponin to see if they “rule in” and I can potentially arrange for an intervention. If I’m in a system that facilitates relatively quick outpatient follow up, I’m more likely to get a 1-2 hour delta troponin on someone I deem rather low risk and try and avoid having to use up an ED obs bed and obtaining an unnecessary echo/stress test.
Walkey et al: Afib in Sepsis
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– This article really adds to mounting evidence supporting the use of BB in tx of afib in sepsis.
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– However, it’s still a retrospective cohort study, which means that no matter how well they thought they matched the cohorts, there may still be inherent biases or unaccounted reasons clinicians decided to use one agent vs. another in certain situations.
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– I personally agree with a recent systematic review on this topic (http://www.ncbi.nlm.nih.gov/pubmed/26702201)
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– which states that we still need LARGE, adequately-powered RCT’s in order to put this to rest, and to determine which BB to use, timing, duration, dosing, patient selection issues, etc.
Gimenez et al: One hour trop ROMI
– More data supporting early ROMI in low risk patients. Another article showed a 1 hour rule out with troponin T, this one applies to troponin I, which is what we use here.
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– It is common sense, but still interesting to see that regardless of the cause, increasing troponin is associated with higher mortality.
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– We currently practice in a changing paradigm in how we take care of low risk chest pain patients. The practice variation, amongst our group, and the country, is huge, even among my own day-to-day practice. We should really consider building our own institutional policy to standardize care.
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– There will be an awesome heated point-counter-point debate at the All Boston Conference on 4/27 led by our very own Jim Feldman that is sure to shed some more light on this topic. BE THERE!
1 hr ROMI
Strengths:
– Multi-center, decent patient recruitment for both derivation/validation, they deviated and validated an algorithm. I commend the authors for not splitting the data into multiple papers.
Limitations:
– Like Abbas said, they lost ~500 patients b/c they couldn’t draw a 2nd troponin (too sick, getting imaging and not available for 2nd lab draw, etc.)
– >60% of patients have unknown final diagnoses. It is interesting that 57% of the patient’s studied had “non-cardiac” chest pain. What is causing all these mimickers!?
-Excluded renal failure patients
Main Outcomes:
– 30 day mortality;
– using the validation cohort, they were able to rule out 50% of patients with a 1h troponin. That’s substantial because they don’t need to go to the EDOU or need to get a stress test (immediately anyways).
Does reading this article change your practice? If so, how?
– I’m not sure about our particular Troponin marker…it’d be interesting to talk to the lab and see if we have the “high-sensitivity.” We should definitely look into using it though and developing an advanced diagnostic protocol for low-risks chest pain. This would take a lot of variability out of these patient’s care. I think patients would like this too because they can go home earlier knowing they have a very very low likelihood of having cardiac dz.
Gimenez et al. One hour Trop I ROMI
1. What are some strengths of the study?
As others have mentioned, strengths include multicenter study with a large sample size. The study also addresses an important issue that potentially affects patient care, patient experience, overcrowding / department flow, and reducing costs to the healthcare system.
2. What are the limitations?
The study would have been stronger if it had been a randomized control trial.
3. What are the main outcomes of the study?
The primary end point was 30 day mortality. The study also looked at 360 day mortality.
4. Does reading this article change your practice? If so, how?
I already practice a 2 hour rule-out if the patient has a TIMI score = 0, which is part of ACEP’s chest pain guidelines. See here for more information: http://www.emlitofnote.com/2012/05/adapt-2-hour-rule-out.html. Although a 1 hour rule-out appears to be sufficient, it would be nice if it had endorsement from major emergency medicine organizations.
Walkey – Treatment of Afib during Sepsis
How has reading the article changed your practice?
I think that this article has made me think more about reaching for BB first in treating Afib with RVR in sepsis. That said, I think that there are other variables to consider when thinking about what agent to choose – hemodynamics, which agent the patient is taking at home, and ability to titrate the medication (i.e. diltiazem can be titrated as a drip, whereas metoprolol cannot be).
What information had you believed in previously that were debunked by reading this article?
I was under the impression that there was no clear difference between CCB and BB in treating afib with RVR. This article focuses specifically on sepsis, which may be why there is a mortality difference that the authors were able to demonstrate
What new information did you learn from reading this article?
I learned that there is not only evidence that BB can be beneficial in afib during sepsis, but that there are other studies showing that they can be useful in SINUS tachycardia in septic shock! Clearly not the standard of care, but I would be interested in seeing some more prospective studies on this topic
What are current areas of uncertainty on this topic that can be potential areas for research?
I think the big downside of this paper is that it was a retrospective study. I would love to see a prospective RCT on this topic.
Strengths:
-About 900 pts in both derivation and validation groups
-Most helpful for rule-out it seems to me, especially in low risk pts that we can avoid admitting to ED obs. Andrew, thanks for posting about the 2hr trop rule out
-Question, are we considering the duration or onset of CP when doing a 1hr, 2hr trop rule out? Do we limit this to patients who CP began at least 4-6 hours prior to arrival?
Limitations:
-Substantial number of pts that ruled in had trop elevations from causes other than ACS
Outcomes:
-30 day mortality, 0% in rule out group
Practice:
Practice, You talking bout practice? Jk. I still do what my attending tells me too. But hopefully more data emerges regarding 1-2 hour rules out by the time I graduate. Would be a nice tool to reduce low risk CP r/o admissions.
I wish I had an attending to make the call for me haha.
The whole low risk chest pain issue is such a quagmire! But I think we’re moving towards a different standard of care with increasing literature like this.
Afib in Sepsis:
– Strengths: Large study with national data. Great to see a comparison of the 4 major meds (and not just BB, CCB). Author notes study’s many limitations. Subgroup analyses were completed w/ HTN as subgroup to account for BB/CCB being used as HTN meds. Did a pretty good job at keeping cohorts matched.
– Limitations: Retrospective cohort study. PO meds not taken into consideration (53% of patients were excluded based on this criterion!). Disease severity difficulty to define and factor into data – likely a significant confounding factor. Data was admin data therefore lacked detailed sequence on charts. Heart rate control and conversion to NSR were NOT looked at! Considering that these pt’s were septic (some of which likely pretty sick), the role of cardioversion was not measured. Authors did not account for pt’s home afib meds and how they were similar (or not) to meds taken during hospitalization.
– Outcomes: CCB’s are most common blocking agent used for AF during sepsis. However, BB > CCBs, digoxin, amiodarone regarding hospital mortality.
– Changed practice? More recently I’ve been favoring the CCB > BB during afib (albeit most of the times the pt was not in sepsis) after witnessing a few attempts with BB that did not result in a positive outcome (2nd attempt w/ CCB did). However, I should mention that these experiences were in patients not w/ sepsis and taking PO meds (ie, would’ve been excluded in the study). After reading the article, I’m more likely to continue starting with the BB and then move to CCB if needed.
1hr ROMI
– Strengths: Large study, multicenter. Two independent cardiologists used many data (including echo, angio, etc.) to define AMI as an outcome for the purposes of the study. Validation f/b derivation of algorithm. Good lit review looking at other early ROMI studies. An additional strength for us EM-centric folks was that all patients were from ED.
– Limitations: Not generalizable anywhere outside ED. Did not include CKD patients.
– Outcomes: Using high sensitivity troponin I in a simple 1hr algorithm has a NPV of 99.6% and PPV of 70% in patients with p/w suspected AMI.
– Changed practice? I’m not even sure if we use high-sensitivity troponins at BMC (I or T). By the looks of things, it seems that we’re slowly getting to a place where we can standardize ROMI. As an intern, it’s kind of been a bit all over the place depending on the attending or senior resident as to who gets ROMI’d and who gets to go home after p/w low-risk CP. Perechoky’s reference is pretty solid and I’ll think I’ll start to use it.
Afib in Sepsis Article
Strengths: large study, adds to the lack of literature re: afib management in sepsis. Sam and I did a CCU talk about a female with afib w/ RVR and sepsis. It was difficult to find guidelines about management however BB did seem to have improved outcomes like this study. It is unclear which BB were utilized in this study. From my research on the topic, people seemed to favor esmolol. Esmolol would be a good first line choice in a hypotensive pt with afib due to its short time of action. If a patient drops their pressure in response to esmolol then it’s quick on, quick off.
Limitations: significant, retrospective, cohort, although cohorts were well matched, there was no clinical data about how “septic” patients were initially. Initial BP would likely alter which agent is used as first line.
Outcomes: hospital mortality
Practice: Doesn’t particularly change practice but important to consider BB over CCB as first line agents for pts with afib and sepsis. I think practice will vary greatly by provider and the pt’s initial presentation (degree of hypotension, etc).