Critical pathways in cardiology
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In this Emergency Medicine Cardiac Research and Education Group (EMCREG)-International Proceedings Monograph from the October 20, 2018, EMCREG-International Multidisciplinary Consensus Panel on Management of Severe Bleeding in Patients Treated With Oral Anticoagulants held in Orlando, FL, you will find a detailed discussion regarding the treatment of patients requiring anticoagulation and the reversal of anticoagulation for patients with severe bleeding. For emergency physicians, critical care physicians, hospitalists, cardiologists, internists, surgeons, and family physicians, the current approach and disease indications for treatment with anticoagulants such as coumadin, factor IIa, and factor Xa inhibitors are particularly relevant. When a patient treated with anticoagulants presents to the emergency department, intensive care unit, or operating room with severe, uncontrollable bleeding, achieving rapid, controlled hemostasis is critically important to save the patient's life. ⋯ The evaluation and treatment of the patient with severe bleeding as a complication of oral anticoagulant therapy are discussed from the viewpoint of the emergency physician, neurocritical and cardiovascular critical care intensivist, hematologist, trauma and acute care surgeon, hospitalist, cardiologist, electrophysiologist, and pharmacist in an approach we hope that the reader will find extremely practical and clinically useful. The clinician learner will also find the discussion of the resumption of oral anticoagulation for the patient with severe bleeding after effective treatment important because returning the patient to an anticoagulated state as soon as feasible and safe prevents thrombotic complications. Finally, an EMCREG-International Severe Bleeding Consensus Panel algorithm for the approach to management of patients with life-threatening oral anticoagulant-associated bleeding is provided for the clinician and can be expanded in size for use in a treatment area such as the emergency department or critical care unit.
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Review
Obstructive Sleep Apnea and Atrial Fibrillation: Pathophysiology and Implications for Treatment.
Obstructive sleep apnea (OSA) is increasingly recognized as an important risk factor for arrhythmogenesis. Epidemiological and clinical studies have suggested a strong association between OSA and atrial fibrillation (AF). With the increasing global epidemic of obesity, the incidence of OSA is also expected to rise. ⋯ The epidemiological and pathophysiological associations between OSA and AF have significant implications on the treatment outcomes of rhythm-control strategies for AF. Adequate screening and optimal management of OSA are of key importance to help improve the clinical outcomes following cardioversion and CA. In this review, we sought to describe the role of various mechanisms by which OSA mediates the pathogenesis of AF and contributes to adverse outcomes following CA.
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Although coronary artery calcium (CAC) scoring has an established role in risk-stratifying asymptomatic patients at intermediate risk of coronary heart disease (CHD), its utility in the evaluation of patients with chest pain is uncertain. We conducted a literature review of articles investigating the utility of: (1) CAC scoring in elective patients with indeterminate chest pain symptoms, (2) CAC as a "gatekeeper" in the triage of patients presenting to the emergency department (ED) with chest pain, and (3) the cost-effectiveness of the use of CAC scoring in the ED. We also evaluated the predictive accuracy of the absence of CAC in a pooled analysis of applicable studies. ⋯ More importantly, a CAC score of 0 in low- and intermediate-risk ED populations with chest pain had a high negative predictive value (99.4%) for CHD events over an average follow-up of 21 months. CAC scoring also seems cost-effective in this population. Although further research is needed, carefully selected ED patients with a normal electrocardiogram, normal cardiac biomarkers, and CAC = 0 may be considered for early discharge without further testing.
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Hospitals and emergency departments face the challenges of escalating healthcare costs, mismatched resource utilization, concern over avoidable admissions, and hospital and emergency department overcrowding. One approach that has been used by hospitals to address these issues is the use of emergency department observation units. Research in this setting has increased in recent years, leading to a better understanding of the role of these units and their unique benefits. ⋯ Benefits include a decrease in diagnostic uncertainty, lower cost and resource utilization, improved patient satisfaction, and clinical outcomes that are comparable to admitted patients. As more hospitals begin to use observation units, there is a need for further education and research in how to optimize the use of emergency department observation units. The purpose of this article is to provide a general overview of observation units, including advancements and research in this field.