Cardiology

How to Spot Ischemia in RBBB Patients

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In non-ischemic right bundle branch block (RBBB) ECGs, we expect discordant ST depression and T wave inversions in leads V1-V3. ST segment elevation, or even an isoelectric ST segment, in these leads is abnormal and should make us concerned for ischemia. See below.

Recalibrating…HEART Score with High-Sensitivity Troponin T

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A recalibrated HEART score ≤ 3 utilizing hs-cTnT ruled out MACE (adjudicated type 1 MI, unplanned coronary revascularization, and all cause death) at 30 days at a sensitivity of 98.5% and NPV of 99.7% with the ability to discharge 46.5% of patients in this cohort. 

Source
HEART Score Recalibration Using Higher Sensitivity Troponin T. Annals of emergency medicine, S0196-0644(23)00313-X. 10 Jun. 2023, doi:10.1016/j.annemergmed.2023.04.024 

DOACS Better than Warfarin in A-fib Even in CKD Patients

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Analysis of multiple prior RCTs finds direct oral anticoagulants (DOAC) have improved safety and efficacy vs. warfarin in atrial fibrillation (AF) even as renal function decreases to as low as 25 mL/min.

Source
Direct Oral Anticoagulants Versus Warfarin Across the Spectrum of Kidney Function: Patient-Level Network Meta-Analyses From COMBINE AF. Circulation. 2023 Jun 6;147(23):1748-1757. doi: 10.1161/CIRCULATIONAHA.122.062752. Epub 2023 Apr 12.

Actually, Hyperacute T Waves Can Help Identify Occlusion MI

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Hyperacute T-waves are best conceptualized as being tall and wide relative to the size of the QRS complex, as well as abnormally symmetric, and can be used to aid in early identification of an acute coronary occlusion.

Source
Hyperacute T-waves Can Be a Useful Sign of Occlusion Myocardial Infarction if Appropriately Defined. Ann Emerg Med. 2023 Mar 3:S0196-0644(23)00025-2. doi: 10.1016/j.annemergmed.2023.01.011. Epub ahead of print.

Amiodarone or Lidocaine for Early Shockable OHCA?

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In this secondary analysis of the ALPS trial (Amiodarone, Lidocaine, or Placebo Study), researchers found that early administration of amiodarone (within 8 minutes) is associated with greater functional survival in OHCA with initial shockable rhythm when compared to placebo.

Source
Survival by Time-to-Administration of Amiodarone, Lidocaine, or Placebo in Shock-Refractory Out-of-Hospital Cardiac Arrest. Acad Emerg Med. 2023 Mar 4. doi: 10.1111/acem.14716. Epub ahead of print.

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