Triple- or Dual-Therapy for Anticoagulation and Platelet Inhibition?
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Apixaban and a P2Y12 inhibitor* is likely the safest antithrombotic regimen for patients with atrial fibrillation and recent acute coronary syndrome requiring both oral anticoagulation and P2Y12 platelet inhibition.
Source
Antithrombotic Strategies in Atrial Fibrillation After ACS and/or PCI: A 4-Way Comparison From AUGUSTUS. J Am Coll Cardiol. 2024 Sep 3;84(10):875-885. doi: 10.1016/j.jacc.2024.06.022. PMID: 39197976.
Six-Month MINT RCT Mortality – AMI Transfusion Strategies
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In patients with acute MI, restrictive blood transfusion thresholds (hemoglobin 8g/dL) had similar rates of all-cause death and recurrent MI at 6 months. However, the 6-month hazard of cardiac death was 52% greater (9.0% vs 6.1%; HR 1.52, 95%CI, 1.19–1.94) in the restrictive transfusion group, largely due to increased cardiac death during the first 30 days.
Source
Restrictive or Liberal Transfusion Strategy in Patients With Acute Myocardial Infarction and Anemia: 6-Month Mortality in the MINT Trial. Circulation. 2024 Sep 24;150(13):1064-1066. doi: 10.1161/CIRCULATIONAHA.124.069917. Epub 2024 Sep 2. PMID: 39221566.
Balloon Angioplasty vs Medical Management for Intracranial Artery Stenosis
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For patients with TIA or stroke due to severe (70-99%) symptomatic intracranial atherosclerotic stenosis (sICAS) of the major intracranial arteries, submaximal balloon angioplasty may become a first-line therapy option based on the BASIS trial. Current first-line therapy will remain medical management, with catheter-based interventions such as submaximal balloon angioplasty and intracranial artery stenting reserved for patients with stroke recurrence on maximal medical therapy until a larger multinational study can be completed.
Source
Balloon Angioplasty vs Medical Management for Intracranial Artery Stenosis: The BASIS Randomized Clinical Trial. JAMA. 2024 Oct 1;332(13):1059-1069. doi: 10.1001/jama.2024.12829. PMID: 39235816; PMCID: PMC11378071.
LAMP RCT – Telehealth, Non-Opioid Treatment for Chronic Pain
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A self-paced, telehealth mindfulness-based intervention for chronic pain was effective, affordable, and scalable.
Source
Telehealth Mindfulness-Based Interventions for Chronic Pain: The LAMP Randomized Clinical Trial. JAMA Intern Med. 2024 Oct 1;184(10):1163-1173. doi: 10.1001/jamainternmed.2024.3940. Erratum in: JAMA Intern Med. 2024 Oct 1;184(10):1270. doi: 10.1001/jamainternmed.2024.5487. PMID: 39158851; PMCID: PMC11334014.
The SQuiD Is Back! Subcutaneous Insulin for DKA
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SQuID is effective in managing DKA, with improvements in time to anion gap closure and ED length-of-stay compared to intravenous insulin protocols.
Source
SQuID (subcutaneous insulin in diabetic ketoacidosis) II: Clinical and operational effectiveness. Acad Emerg Med. 2024 Sep 23. doi: 10.1111/acem.15020. Epub ahead of print. PMID: 39308229.
How to Treat Hypertensive Emergency
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Hypertensive emergencies are associated with high morbidity and mortality and require careful and specific strategies to diminish pressure-mediated organ injury depending on the presentation.
Do Discharged Patients With Severe Hypertension Have Poor Outcomes?
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This was a multi-hospital retrospective study of patients who presented to the emergency department with severe hypertension without end organ damage. The authors found that the 1 year rate of major adverse cardiovascular events (MACE) was 15.5%.
Source
Emergency Department Blood Pressure Treatment and Outcomes in Adults Presenting with Severe Hypertension. West J Emerg Med. 2024;25(5):680-689.
Hypertensive Crisis Averted…New AHA Statement on Asymptomatic Hypertension
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This article emphasizes the difference between hypertensive emergency and asymptomatic elevated blood pressure (BP); while hypertensive emergency requires prompt treatment to lower BP, treatment of asymptomatic elevated BP in acute care settings may be harmful.
Source
The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association. Hypertension. 2024 Aug;81(8):e94-e106. doi: 10.1161/HYP.0000000000000238. Epub 2024 May 28. PMID: 38804130.
How Common Are Serious Adverse Reactions to Antibiotics?
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This large study in Canada of patients aged 66+ found that all commonly prescribed oral antibiotics were associated with an increased risk of serious cutaneous drug reactions (cADRs) relative to macrolides; however, few of these reactions led to hospitalization and an even smaller amount were true cutaneous emergencies (SJS/TEN).
Source
Oral Antibiotics and Risk of Serious Cutaneous Adverse Drug Reactions. JAMA. 2024 Sep 3;332(9):730-737. doi: 10.1001/jama.2024.11437. PMID: 39115856; PMCID: PMC11310841.
Diagnostic Approach to Syphilis – Not So Painless After All
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There continues to be a lack of evidence to strongly recommend one treponemal assay over another in the diagnosis of syphilis, particularly given the varying accuracy of each test depending on the stage of the disease. For now, this review suggests the diagnostic algorithm recommended by the CDC (see below!) seems to be a reasonable approach, but more trials are needed to refine this.
Source
Operating Characteristics of Diagnostic Tests for Syphilis. Acad Emerg Med. 2024 Sep 6; 00:1-3. doi: 10.1111/acem.15008. PMID: 39239836.