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Key Clinical Message: The case underscores the necessity of adaptable airway management strategies in aortic dissection surgeries complicated by carinal shift. Successful lung isolation was achieved using a single‐lumen endotracheal tube after failed attempts with traditional methods and bronchial blockers. [ABSTRACT FROM AUTHOR]

Introduction: a hypertensive crisis is characterized by a state of acutely elevated blood pressure. It can arise as a consequence of uncontrolled chronic hypertension or manifest suddenly in previously healthy individuals. Aim: to explore the impact of cardiovascular risk factors on the type and outcome of hypertensive crises (HC). Additionally, to investigate the occurrence of new cardiovascular events in a six-month period and define possible risk factors that may influence this. Materials and methods: the data from the hospital electronic medical records of patients presented with HC at the Emergency Medicine Clinic of the Clinical Center of the University of Sarajevo over a six-month period (01.07.-31.12.2023) were retrospectively collected. Data collection encompassed blood pressure levels, age, sex, history of chronic hypertension, smoking status, and presence of diabetes mellitus and dyslipidemia as cardiovascular risk factors. Outcomes after initial admission (1. discharge, 2. hospitalization and 3. death) and after six-month follow up (1. absence of readmission, 2. readmission and 3. death) were recorded. Results: the study included 243 patients: 66 (27.2%) with hypertensive emergencies and 177 (72.8%) with hypertensive urgencies without significant difference between these groups regarding age, history of chronic hypertension, presence of dyslipidemia, smoking status, and presence of diabetes mellitus (p>0.05). Men were predominated in HE, while women were predominated in HU group (p<0.05). Diastolic blood pressure values were higher in HE patients [median (IQR) 110(20) vs. 100(10)] (p<0.05). After initial treatment 98.3% of HU patients were discharged, 92.4% were hospitalized and 3% of HE patients died. After a 6-month follow-up, there was no significant difference in the number of readmissions between these two groups (p>0.05), but mortality was significantly higher in HE (15.15% vs 6.21%) (p<0.05). There was no significant difference in risk factors between patients with the observed outcomes (p>0.05) except that the age was higher in deceased patients (p<0.05). Conclusion: male gender and higher DBP have been identified as risk factors for the development of HE, the need for hospital treatment, and increased in-hospital and six-month mortality. Older age represents a risk for readmissions and mortality. [ABSTRACT FROM AUTHOR]

Copyright of Herz is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Key Clinical Message The case underscores the necessity of adaptable airway management strategies in aortic dissection surgeries complicated by carinal shift. Successful lung isolation was achieved using a single‐lumen endotracheal tube after failed attempts with traditional methods and bronchial blockers.

ABSTRACT:Audience: Emergency medicine residents and medical students on emergency medicine rotation.Introduction: Acute pulmonary edema is a common and potentially fatal presentation in the emergency department. More than 1 million patients are admitted annually with a diagnosis of pulmonary edema secondary to cardiac causes.1 Pulmonary edema is broadly split into two main categories: cardiogenic and noncardiogenic. Cardiogenic pulmonary edema is characterized by acute dyspnea caused by the accumulation of fluid within the lung’s interstitial and/or alveolar spaces, which is the result of acutely elevated cardiac filling pressures.2 Noncardiogenic pulmonary edema is characterized by fluid accumulation within the alveolar space in the absence of elevated pulmonary capillary wedge pressure.2 These patients often present critically ill, and rapid identification and aggressive management is paramount in caring for patients with pulmonary edema. Dyspnea is the most common presentation with a sensitivity of 89% but a low specificity of 51%.3 Workup of pulmonary edema often includes laboratory testing, electrocardiogram (EKG), chest x-ray (CXR), and often bedside ultrasound (US) and echocardiography.4 Pulmonary edema management depends on the etiology but is often focused on preload and afterload reduction. Diuretics, nitrates, and optimizing ventilatory support through non-invasive and invasive strategies are the mainstay of treatment.Educational Objectives: At the end of this practice oral boards case, the learner will:1) recognize unstable vital signs (VS) and intervene to stabilize ventilation and oxygenation, 2) demonstrate the ability to obtain a complete medical history including the important characteristics of chest pain, 3) demonstrate an appropriate exam on a patient, 4) order the appropriate evaluation studies for a patient with complaints of dyspnea, 5) interpret the results of diagnostic evaluation and diagnose Non- ST elevation myocardial infarction (NSTEMI) and pulmonary edema, 6) order appropriate management of pulmonary edema and NSTEMI, and 6) demonstrate effective communication with patient and family members.Educational Methods: Practice oral boardsResearch Methods: Immediate Feedback was solicited from the learners and observers participating in the case both by verbal discussion and completion of a rating for the case following the debriefing. The efficacy of the educational content was assessed by comparing scoring measures across residents based on the training year. Scoring measures of the American College of Graduate Medical Education (ACGME) core competencies were performed using a scale from 1 – 8, 1- 4 being unacceptable performance and 5 – 8 being acceptable. Efficacy was assumed based on full completion of the case by the residents who acted as practice oral board candidates, and a debriefing session followed to discuss the key components of the case.Results: This case was presented to twelve Emergency Medicine Residents, seven PGY 1 and five PGY 2 at a relatively new residency program. The overall average score for the residents was 5.62. The PGY 1 Residents’ average on the case was 5.56, and the average for the PGY 2 Residents was slightly better at 5.70. The slight improvement noted by the PGY 2 Residents is likely attributable to more clinical experience; however, both classes did not have any prior exposure to the oral board format until this simulated experience. Six residents completed all critical actions in the case. Of those who missed a critical action, failing to diagnose NSTEMI and consulting cardiology were the most common. All learners found educational value in the case with an overall rating of 4.83 (1-5 Likert scale, 5 being excellent).Discussion: Acute pulmonary edema and NSTEMI are common diagnoses that will be frequently encountered for most emergency physicians. This case highlights the need for early identification and aggressive management of the patient presenting with respiratory distress. The differential for respiratory distress is large, but most learners were able to quickly identify pulmonary edema based on the exam findings of jugular vein distention (JVD), rales, and lower extremity edema. Most learners quickly escalated to a non-rebreather mask and ultimately to BPAP (bilevel positive airway pressure) without requesting to intubate the patient. There was notable variation in the approach to administering nitrates, but most ordered an intravenous (IV) nitroglycerin (NTG) drip and requested pharmacy assistance in dosing. Diuretics were ordered by all the learners, but some were hesitant to start early because they felt the effect would be delayed. Some of the residents did not identify ischemic changes on the EKG at first glance but did request to review a second time when the troponin result was positive. All residents gave aspirin after noting the positive troponin, but not all were able to make a clear diagnosis of NSTEMI or consult cardiology. Although the case was relatively straightforward, residents enjoyed early diagnosis and aggressive management of the patient with impending respiratory failure. Many residents are asking for an ultrasound early in the workup of this patient presenting in respiratory distress. Although not a critical action in this case, it highlights the emphasis placed on ultrasonography in the current emergency medicine curriculum.Topics: Pulmonary Edema, Cardiovascular emergencies, NSTEMI.

Cardiovascular diseases are the leading cause of death, with many lives being affected by critical emergencies like heart attacks, strokes, and other acute conditions. Recognizing the early warning signs is crucial for highlighting the need for immediate medical attention, especially since a quick intervention may significantly improve short and long-term patient outcome. Artificial intelligence (AI) has become a key technology in healthcare, and especially in the cardiovascular field. AI, and in particular deep learning is well suited for automatically analyzing medical images, signals, and data. Its success rests on the availability of large amounts of curated data, and the access to high performance computing infrastructures for training the deep-learning algorithms. Thus, in cardiovascular care, AI plays a dynamic role in disease detection, predicting disease outcome, and guiding treatment decisions. This review paper details and discusses the current role of AI for the most common cardiovascular emergencies. It provides insight into the specific issues, risk factors, different subtypes of the diseases, and algorithms developed to date, followed by an outlook. [ABSTRACT FROM AUTHOR]

The pericoronary fat attenuation index (FAI) is an emerging computed tomography-derived marker for measuring vascular inflammation at coronary vessels. It holds prognostic significance for major cardiovascular events and enhances cardiac risk assessment, complementing traditional risk factors and coronary artery calcium scores. However, the impact of local coronary circulation factors on pericoronary inflammation development in right versus left coronary arteries has not been clearly understood. This study aimed to investigate the regional differences in inflammation levels between the right and left coronary arteries in four clinical scenarios: acute coronary event in the follow-up period, post-COVID patients, recent percutaneous intervention, and unstable angina with significant lesions on native coronary arteries. The study included 153 patients (mean age 62 years, 70.5% male) who underwent clinically indicated coronary computed tomography angiography (CCTA). Vulnerable plaque features were analyzed to identify high-risk plaques. FAI and the FAI score, a score integrating risk factors and age, were calculated for each case at the left anterior descending artery (LAD), circumflex artery (LCX), and right coronary artery (RCA). A total of 459 coronary arteries were analyzed. Both FAI and FAI scores were higher in the RCA (15.23 ± 11.97) compared to the LAD (10.55 ± 6.78) and (11.48 ± 6.5) LCX (p = 0.02). FAI values showed a significantly higher level at the RCA (−71.25 ± 7.47 HU) compared to the LCX (−76 ± 7.68 HU) and the LAD (−73.04 ± 8.9 HU, p <0.0001). This trend persisted across all subgroups, including post-COVID CT scans (−75.49 ± 7.62 HU for RCA vs. −72.89 ± 9.40 HU for the LCX vs. −71.28 ± 7.82 HU for the LAD, p = 0.01) and patients with high-risk plaques (20.98 ± 16.29 for the RCA vs. 11.77 ± 7.68 for the LCX vs. 12.83 ± 6.47 for the LAD, p = 0.03). Plaques in different coronary areas show varied vulnerability and inflammation levels. The RCA, in particular, demonstrates greater inflammation susceptibility, with higher inflammation scores in areas surrounding the coronary plaques. [ABSTRACT FROM AUTHOR]

Objectives: Shock index (SI) and its derivatives play a crucial role in rapid prognosis and risk assessment, particularly in emergent scenarios like ST-segment elevation myocardial infarction (STEMI). Methods: This study was conducted as single-centered and retrospective. A total of 467 cases who met the study criteria with a confirmed STEMI diagnosis were included. SI, modified SI (MSI), age SI (ASI), and agemodified SI (AMSI) scores of the cases were calculated and compared. In this study, p < 0.05 was accepted as the statistical significance level. Results: Calculated scores were compared among cases meeting STEMI criteria. Mortal cases displayed significantly higher SI, MSI, ASI, and AMSI, as well as elevated heart rates and lowered SBP, DBP, and MAP values. ASI exhibited the highest predictive success for mortality (AUC: 0.802), followed by AMSI (AUC: 0.798). AMSI demonstrated superior significance in estimating major adverse cardiovascular events (MACE) (p < 0.001 for each parameter). Conclusions: ASI proved most effective in gauging mortality risk, while AMSI excelled in predicting MACE risk among SI derivatives. These indices hold promise for guiding patient triage and emergency care in STEMI cases, owing to their simplicity and predictive capacity. [ABSTRACT FROM AUTHOR]

Background: The aim of the long-term Heinz Nixdorf Recall Study (observation period 20 years) was to establish the extent to which computed tomography (CT) improves the predictability of cardiovascular events relative to determination of risk factors alone. Methods: In the period 2000-2003, study staff examined 4355 probands (53% of them female) aged 45--75 years with no signs of cardiovascular disease. The Atherosclerotic Cardiovascular Disease (ASCVD) score was calculated on the basis of demographic data and cardiovascular risk factors. Cardiac CT was carried out over the same period and coronary artery calcification (CAC) was graded according to the Agatston score. Results: The median duration of follow-up was 18.2 years for men and 17.8 years for women. Myocardial infarction or stroke occurred in 458 (11%) of the 4154 participants with complete data. Overall, estimation of risk using a combination of ASCVD score and CAC grade was superior to the ASCVD score alone--even after 10 and 20 years. Classification into established risk categories improved by 12.2% (95% confidence interval: [5.3%; 18.1%]). In the highest ASCVD risk category, we observed occurrence of a cardiovascular event over 20 years for 14% [5.0%; 23.1%] of probands with a CAC score = 0 but for 34.2% [27.5%; 41.4%] of those with a CAC score ≥ 400. In the lowest ASCVD risk category, an event occurred in 2.4% [1.4%; 3.7%] of probands with a CAC score = 0 and in 23.5% [2.3%; 35.8%] of those with a CAC score ≥ 400. Conclusion: Even after 20 years, individual risk prediction is improved by addition of CT-based determination of coronary artery calcification to the ASCVD score. Therefore, assessment of ASCVD risk factors should be complemented more widely by cardiac CT in the primary prevention of cardiovascular disease. [ABSTRACT FROM AUTHOR]

Aim and Objective: The aim of this study is to find out the time onset of acute myocardial infarction in different times and relationship between myocardial infarction symptoms of patients. Background: Acute Myocardial Infarction is occurring because of sustained ischemia, causing irreversible myocardial cell death. Thrombus formation causes 80% to 90% of all acute myocardial infarction. Design: A quantitative, cross sectional study design. Methods: A study was conducted in coronary care unit on Acute Myocardial Infarction patient at Erbil Hospitals of Hawler, Rizgary and East Emergency Teaching Hospitals. This study was started from May, 2019 to October of 2019. Results: A non-probability convenience method used to recruit patients. Informal oral consent was obtained. Data was analysed through the Statistical Package for Science Service, V 20. Descriptive statistical analyses that was include. Frequency and percentage. The Inferential statistical data analysis through Chi-square and Fisher's Exact tests: used to find out the association between categorical variables. Probability of p-value and considered significant at the level of = 0.05. The researcher was collected the data through face to face interview after taking an agreement from patients and the samples were interviewed via one session about half an hour with protect patient trust and confidentially. Conclusions: The results of the study indicated that more than half of the study sample were had severe chest pain in the morning and nearly one third of them were had diaphoresis and shortness of breathing at night. The majority of the sample were had no nausea, vomiting and most of them were felt palpitation at night. [ABSTRACT FROM AUTHOR]

ABSTRACT: Audience: This curriculum, created and implemented at The Ohio State University Wexner Medical Center, was designed to educate our emergency medicine (EM) residents, PGY-1 to PGY-3, as well as medical students and attending physicians. Introduction: In 2013, chest pain alone was the principal reason for visit for over 6 million Emergency Department visits in the United States. This represents 4.9% of all Emergency Department visits.1 Residents must be proficient in the differential diagnosis and management of the wide variety of cardiovascular emergencies. The flipped classroom curricular model emphasizes self-directed learning activities completed by learners, followed by small group discussions pertaining to the topic reviewed. The active learning fostered by this curriculum increases faculty and learner engagement and interaction time typically absent in traditional lecture-based formats.2-4 Studies have revealed that the application of knowledge through case studies, personal interaction with content experts, and integrated questions are effective learning strategies for emergency medicine residents.4-6 The Ohio State University Wexner Medical Center EM Residency didactic curriculum recently transitioned to a “flipped classroom” approach.7-10 We created this innovative curriculum aimed to improve our residency education program and to share educational resources with other EM residency programs. Our curriculum utilizes an 18-month curricular cycle to cover the defined emergency medicine content. The flipped classroom curriculum maximizes didactic time and resident engagement, fosters intellectual curiosity and active learning, and meets the needs of today’s learners. 3,11,13Aims/Goals: We aim to teach the presentation and management of cardiovascular emergencies through the creation of a flipped classroom design. This unique, innovative curriculum utilizes resources chosen by education faculty and resident learners, study questions, real-life experiences, and small group discussions in place of traditional lectures. In doing so, a goal of the curriculum is to encourage self-directed learning, improve understanding and knowledge retention, and improve the educational experience of our residents. Methods: The educational strategies used in this curriculum include small group modules authored by education faculty and content experts based on the core emergency medicine content. This program also includes resident-submitted questions that were developed during review of the content. The question and answer format of the Socratic Method--with a focus on fostering an open learning environment, not negative “pimping”-type questionin--is used during small group sessions to encourage active participation and discussion; small groups also focus on the synthesis and application of knowledge through the discussion of real life experiences. The use of free open access medical education (FOAM) resources allows learners to work at their own pace and maximize autonomy. Topics: Emergency medicine, flipped classroom, medical education, cardiovascular emergencies, pedagogy, teaching.

Abstract Background The goal of improving quality through centralisation of specialised medical services must be balanced against potential harm caused by delayed access to emergency treatments in rural areas. This study aims to assess the duration of transfers of critically ill patients with cardiovascular emergencies from smaller hospitals to major medical centres by a helicopter emergency medical service (HEMS) in Switzerland. Methods This retrospective observational cohort study includes all consecutive emergency interfacility transfers (IFTs) conducted by Switzerland’s largest HEMS provider between July 3rd, 2019, and March 31st, 2021. All patients with acute myocardial infarction, non-traumatic strokes, ruptured aortic aneurysms, and other acute vascular emergencies were included. The duration and distance of each HEMS IFT were compared to calculated distances and duration of travel for the same missions using ground-based transportation (GEMS). The ground-based mission distance beyond which the total mission duration of HEMS is expected to be faster than GEMS was calculated. Findings A total of 645 patients were transferred for stroke (n = 364), myocardial infarction (n = 252) and other acute vascular emergencies (n = 29). The median total mission duration from emergency call to landing at the destination was 59.9 (IQR 51.5 to 70.5) minutes. The median road distance for the same missions was 60 (IQR 43 to 72) km. Regression analysis revealed that HEMS is expected to be faster if the road distance is more than 51.3 km. Interpretation Centralisation of specialised medical services should be accompanied by a comprehensive and specialised rescue chain. HEMS in Switzerland ensures time-sensitive IFT in medical emergencies, even in topographically challenging terrain. Graphical Abstract

The role of cardiac biomarkers in diagnosing acute myocardial infarction is undoubted. In the 2020 guidelines of the European Society of Cardiology, the measurement of cardiac peptides to gain prognostic information has a class IIa indication in all patients with ACS. In emergency care, ruling out a non-ST elevation myocardial infarction requires documentation of normal levels of cardiac biomarkers, which remain stable or have very small variations within several hours. This review aims to summarize the current knowledge and recent progresses in the field of cardiac biomarker discovery, from their routine use in emergency rooms to their prognostic roles in modern risk assessment tools. Integrated approaches combining cardiac troponin with other biomarkers of ventricular dysfunction or inflammation, or with modern cardiac imaging in emergency care are also presented, as well as the role of modern algorithms for serial troponin measurement in the modern management of emergency departments. [ABSTRACT FROM AUTHOR]

Acute Myocardial Infarction (AMI) is the immediate cessation of the blood supply to the heart muscle and occurs due to lack of oxygen and is one of the most frequent medical emergencies. ST-Elevation Acute Myocardial Infarction (STEMI)is one of the major cardiological emergencies which is associated with complications of heart failure, arrhythmia, and high mortality. The main treatment is coronary artery recanalization of the involved artery in the shortest time possible. Percutaneous transluminal coronary angioplasty has shown the best results of AMI treatment. Reperfusion of the ischemic myocardium can be achieved by pharmacologic methods (thrombolysis) and PCI (Percutaneous Coronary-arteries Intervention). Purpose of the study: The study is of cohort-prospective type. It is a study for the coronary-angiography evaluation of the current treatment of STEMI at the University Hospital Center in Tirana in patients undergoing thrombolysis with streptokinase or reteplase (choice is based on the specific case), and the effect of predisposing factors upon the mortality of STEMI. Materials and methods: this study included all patients admitted to the department of cardiologic resuscitation, from 01 Feb 2013, until 05 Jul 2013 (56 patients, of whom 26 were females and 30 were males, with an identical average age of 56.0 ±10.0 years old) diagnosed with STEMI in whom thrombolysis with reteplase or streptokinase has been performed according to previously tested protocols, respecting the absolute contraindications for the application of reperfusion procedure. Thrombolysis was performed in patients who presented within 6 hours since the onset of pain. Follow-up includes days of hospitalization (cardiology resuscitation + cardiology clinic I or II). Results: Data analysis showed Thrombolysis in Myocardial Infarction (TIMI) 3 in 82% of the total cases; The group of patients treated with streptokinase showed TIMI 3 of 70% and the group of patients treated with reteplase showed TIMI 3 of 91%. The total mortality rate was 6.9% (3 patients) and these were part of the group treated with reteplase. Predisposing factors for high mortality in patients undergoing thrombolysis such as age, sex, diabetes mellitus (DM) type II (prevalence of DM type II was 33.9% of all patients, of whom 41% of the patients treated with RP and 22% of patients treated with ST, p=0.0001) and TIMI had a statistical significantly higher risk factors in the group treated with reteplase. Conclusion: Thrombolysis of STEMI patients presents an effective recanalizing alternative when the patient presents within the first few hours since the onset of pain onset, a conclusion achieved by TIMI-based coronary angiography assessment. Mortality in thrombolysis is related to factors such as: age, gender, high blood pressure (BP), DM, and other comorbid factors. [ABSTRACT FROM AUTHOR]

Background: The goal of improving quality through centralisation of specialised medical services must be balanced against potential harm caused by delayed access to emergency treatments in rural areas. This study aims to assess the duration of transfers of critically ill patients with cardiovascular emergencies from smaller hospitals to major medical centres by a helicopter emergency medical service (HEMS) in Switzerland. Methods: This retrospective observational cohort study includes all consecutive emergency interfacility transfers (IFTs) conducted by Switzerland's largest HEMS provider between July 3rd, 2019, and March 31st, 2021. All patients with acute myocardial infarction, non-traumatic strokes, ruptured aortic aneurysms, and other acute vascular emergencies were included. The duration and distance of each HEMS IFT were compared to calculated distances and duration of travel for the same missions using ground-based transportation (GEMS). The ground-based mission distance beyond which the total mission duration of HEMS is expected to be faster than GEMS was calculated. Findings: A total of 645 patients were transferred for stroke (n = 364), myocardial infarction (n = 252) and other acute vascular emergencies (n = 29). The median total mission duration from emergency call to landing at the destination was 59.9 (IQR 51.5 to 70.5) minutes. The median road distance for the same missions was 60 (IQR 43 to 72) km. Regression analysis revealed that HEMS is expected to be faster if the road distance is more than 51.3 km. Interpretation: Centralisation of specialised medical services should be accompanied by a comprehensive and specialised rescue chain. HEMS in Switzerland ensures time-sensitive IFT in medical emergencies, even in topographically challenging terrain. [ABSTRACT FROM AUTHOR]

The new coronavirus (COVID-19) outbreak was declared a pandemic by the World Health Organization on March 11, 2020. Since then, important changes have been observed in the medical world, both in terms of patient management and patient presentations to the hospital. A dramatic decrease in the number of cardiovascular emergencies presenting to the emergency rooms has been reported in every country affected by the COVID-19 pandemic. This resulted mainly from the fear of patients to present at the hospital due to the risk of infection with the new coronavirus. Moreover, a significant increase in the time spent for investigations and specialized treatment has been reported for patients suffering from acute cardiovascular diseases. This adds to the longer times reported from symptom onset to presentation, and also to the longer period spent for triage in the emergency room. The aim of this paper is to highlight the dramatic reduction in the number of cardiovascular emergencies during the COVID-19 period and its possible explanations.

Digitalization in cardiovascular emergencies is rapidly evolving, analogous to the development in medicine, driven by the increasingly broader availability of digital structures and improved networks, electronic health records and the interconnectivity of systems. The potential use of digital health in patients with acute chest pain starts even in the prehospital phase with the transmission of a digital electrocardiogram (ECG) as well as telemedical support and digital emergency management, which facilitate optimization of the rescue pathways and reduce critical time intervals. The increasing dissemination and acceptance of guideline apps and clinical decision support tools as well as integrated calculators and electronic scores are anticipated to improve guideline adherence, translating into a better quality of treatment and improved outcomes. Implementation of artificial intelligence to support image analysis and also the prediction of coronary artery stenosis requiring interventional treatment or impending cardiovascular events, such as heart attacks or death, have an enormous potential especially as conventional instruments frequently yield suboptimal results; however, there are barriers to the rapid dissemination of corresponding decision aids, such as the regulatory rules related to approval as a medical product, data protection issues and other legal liability aspects, which must be considered., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Evidence‐based guidelines are often cited as a means of ensuring high‐quality care for all patients. Our objective was to assess whether emergency department (ED) adherence to core evidence‐based guidelines differed by patient sex and race/ethnicity and to assess the effect of ED guideline adherence on patient outcomes by sex and race/ethnicity. Methods: We conducted a preplanned secondary analysis of data from a multicenter retrospective observational study evaluating variation in ED adherence to five core evidence‐based treatment guidelines including aspirin for acute coronary syndrome, door‐to‐balloon time for acute ST‐elevation myocardial infarction, systemic thrombolysis for acute ischemic stroke, antibiotic selection for inpatient pneumonia, and early management of severe sepsis/septic shock. This study was performed at six hospitals in Colorado with heterogeneous and diverse practice environments. Hierarchical generalized linear modeling was used to estimate adjusted associations between ED adherence and patient sex and race/ethnicity while controlling for other patient, physician, and environmental factors that could confound this association. Results: A total of 1,880 patients were included in the study with a median (IQR) age of 62 (51–74) years. Males and non‐Hispanic whites comprised 59% and 71% of the cohort, respectively. While unadjusted differences were identified, our adjusted analyses found no significant association between ED guideline adherence and sex or race/ethnicity. Patients who did not receive guideline adherent care in the ED were significantly more likely to die while in the hospital (odds ratio = 2.0, 95% confidence interval = 1.3 to 3.2). Conclusions: Longstanding, nationally reported evidence‐based guidelines can help eliminate sex and race/ethnicity disparities in quality of care. When providers know their care is being monitored and reported, their implicit biases may be less likely to impact care. [ABSTRACT FROM AUTHOR]

Copyright of Herz is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: Psoriasis Longitudinal Assessment and Registry (PSOLAR) was designed in 2007 as the first disease-based registry for patients with psoriasis.Objective: The aim of this study was to discuss methodological limitations and post hoc analyses in long-term safety registries using learnings from analyses of a potential safety risk for major adverse cardiovascular events (MACE) in PSOLAR.Methods: PSOLAR is an international observational study of over 12,000 psoriasis patients that was conducted to meet postmarketing safety commitments for infliximab and ustekinumab. A recent annual review of registry data indicated a potential MACE risk for ustekinumab vs. non-biologics based on prespecified COX model regression analyses, which yielded an adjusted hazard ratio (HR) of 1.533 (95% confidence interval [CI] 1.103-2.131). Therefore, we conducted a comprehensive review of key statistical methodology and implemented post hoc analytical methods to address specific limitations.Results: The following limiting factors were identified: (1) inclusion of both prevalent and incident (new) users of biologics; (2) unanticipated imbalances in patient characteristics between treatment cohorts at baseline; (3) limited availability of relevant clinical data after enrollment; and (4) divergence of characteristics associated with outcomes among comparator groups over time. The analysis was modified to include only incident users, propensity scores were used to weight HRs, and adalimumab was deemed a more clinically appropriate comparator. The revised HR was 0.820 (95% CI 0.532-1.265), indicating no meaningful increase in MACE risk for ustekinumab.Conclusion: Our results, which do not support a causal association between ustekinumab exposure and MACE risk, underscore the need for ongoing assessment of analytical methods in long-term observational studies. [ABSTRACT FROM AUTHOR]

Background: There are still gaps regarding the impact of the nationwide lockdown on non-COVID-19 emergency hospitalizations. This study aims to describe the trends in hospitalizations for cardiovascular surgical emergencies in France, before, during and after the first lockdown. Materials and Methods: All adults admitted for mechanical complications of myocardial infarction (MI), aortic dissection, aortic aneurysm rupture, acute and critical limb ischemia, circulatory assistance, heart transplantation and major amputation were included. This retrospective cohort study used the French National Hospital Discharge database. The numbers of hospitalizations per month in 2020 were compared to the previous three years. Results: From January to September 2020, 94,408 cases of the studied conditions were reported versus 103,126 in the same period in 2019 (−8.5%). There was a deep drop in most conditions during the lockdown, except for circulatory assistance, which increased. After the lockdown, mechanical complications of MI and aortic aneurysm rupture increased, and cardiac transplantations declined compared with previous years. Conclusion: We confirmed a deep drop in most cardiovascular surgical emergencies during the lockdown. The post-lockdown period was characterized by a small over-recovery for mechanical complications of MI and aortic aneurysm rupture, suggesting that many patients were able to access surgery after the lockdown.

Aim: Managing the vital parameters in patients recuperating in critical care setups is a routine activity. Hypertensive emergencies are common in critical care patient's post-surgical intervention. Mean Arterial Pressure (MAP) is an essential parameter continually monitored in and has to be maintained in a set physiological value to maintain adequate perfusion to end organs. Material & Methods: Sodium nitroprusside (SNP) is a potent vasoactive drug which is used in interventional cardiology to manage hypertensive emergencies. SNP is administered through intravenous route as an infusion which is difficult to regulate manually. Hence many workers have adopted elements of control engineering to regulate the rate and extent of many hard to infuse drugs by building closed loop drug infusion devices (CL-DIS) powered by many control engineering algorithms like fuzzy logic, artificial neural networks, Proportional Resonance Controller and Fractional Order Proportional Integral Derivative Controller to regulate the infusion. In this work an attempt to conceptualize model and simulate a CL-DIS using a Model Predicative Controller (MPC) is implemented. Results & Discussion: MPC based CL-DIS is modelled and simulated in this work. This is compared against the other popular control engineering algorithms of Proportional Resonance Controller and Fractional Order Proportional Integral Derivative controller and their performance characteristics of peak overshoot, rising response time, settling time, peak response time and noise variation was compared. Conclusion: MPC based CL-DIS has the potential to regulate the infusion of potent vasoactive drug and is capable of doing adaptive controlled drug delivery based on the feedback controller and is capable of operating within constrained set of physiological MAP values between 60 and 70 mm Hg. [ABSTRACT FROM AUTHOR]

The article discusses the use of emergency oxygen for emergency resuscitation or protection against oxygen-deficient atmosphere in aquatic and recreation facilities. The common oxygen-delivery devices are the nasal cannula, nonrebreather mask, resuscitation mask with oxygen inlet, and bag-valve and mask with oxygen-delivery line. It is noted that the emergency oxygen training programs and certification can be avail at organizations that teach the use of emergency oxygen support system.

Objectives: Long-term risk of a major adverse cardiovascular events in ICU survivors who underwent acute renal replacement therapy requires further investigation.Design: Nationwide population-based study using the claims database of Korea.Setting: Index admission cases of ICU survivors in government-designated tertiary hospitals PATIENTS:: The study group consisted of ICU survivors who underwent acute renal replacement therapy, and the control group consisted of those without acute renal replacement therapy. Patients were excluded if they 1) were under age 20, 2) expired within 30 days after discharge, 3) received ICU care for less than 24 hours, 4) had a previous ICU admission, 5) had a history of major adverse cardiovascular event, or 6) had a major adverse cardiovascular event-related cardio/cerebrovascular diseases. The outcomes of the patients who received continuous renal replacement therapy were compared with those of patients who received only intermittent renal replacement therapy.Interventions: None.Measurements and Main Results: Information regarding patient characteristics and treatment modalities was collected and adjusted. The main outcome was major adverse cardiovascular event, including acute myocardial infarction, revascularization, and acute ischemic stroke. Patient mortality and progression to end-stage renal disease were also evaluated. We included 12,380 acute renal replacement therapy patients and 382,018 patients in the control group. Among the study group, 6,891 patients were included in the continuous renal replacement therapy group, and 5,034 in the intermittent renal replacement therapy group. The risks of major adverse cardiovascular event (adjusted hazard ratio, 1.463 [1.323-1.619]; p < 0.001), all-cause mortality (adjusted hazard ratio, 1.323 [1.256-1.393]; p < 0.001), and end-stage renal disease (adjusted hazard ratio, 18.110 [15.779-20.786]; p < 0.001) were higher in the acute renal replacement therapy patients than the control group. When we compared the continuous renal replacement therapy patients with the intermittent renal replacement therapy patients, the risk of major adverse cardiovascular event was comparable (adjusted hazard ratio, 1.049 [0.888-1.239]; p = 0.575).Conclusions: Clinicians should note the increased risk of a long-term major adverse cardiovascular event in acute renal replacement therapy patients and consider appropriate risk factor management. Significant difference in the risk of postdischarge major adverse cardiovascular event was not identified between continuous renal replacement therapy and intermittent renal replacement therapy. [ABSTRACT FROM AUTHOR]

Background: Hypertensive crises are clinical syndromes grouped as hypertensive urgency and emergency, which occur as complications of untreated or inadequately treated hypertension. Emergency departments across the world are the first points of contact for these patients. There is a paucity of data on patients in hypertensive crises presenting to emergency departments in Tanzania. We aimed to describe the profile and outcome of patients with hypertensive crisis presenting to the Emergency Department of Muhimbili National Hospital in Tanzania.Methods: This was a descriptive cohort study of adult patients aged 18 years and above presenting to the emergency department with hypertensive urgency or emergency over a four-month period. Trained researchers used a structured data sheet to document demographic information, clinical presentation, management and outcome. Descriptive statistics with 95% confidence intervals (CIs) are presented as well as comparisons between the groups with hypertensive urgency vs. emergency.Results: We screened 8002 patients and enrolled 203 (2.5%). The median age was 55 (interquartile range 45-67 years) and 51.7% were females. Overall 138 (68%) had hypertensive emergency; and 65 (32%) had hypertensive urgency, for an overall rate of 1.7% (95% CI: 1.5 to 2.0%) and 0.81% (95% CI: 0.63 to 1.0%), respectively. Altered mental status was the most common presenting symptom in hypertensive emergency [74 (53.6%)]; low Glasgow Coma Scale was the most common physical finding [61 (44.2%)]; and cerebrovascular accident was the most common final diagnosis [63 (31%)]. One hundred twelve patients with hypertensive emergency (81.2%) were admitted and three died in the emergency department, while 24 patients with hypertensive urgency (36.9%) were admitted and none died in the emergency department. In-hospital mortality rates for hypertensive emergency and urgency were 37 (26.8%) and 2 (3.1%), respectively.Conclusion: In our cohort of adult patients with elevated blood pressure, hypertensive crisis was associated with substantial morbidity and mortality, with the most vulnerable being those with hypertensive emergency. Further research is required to determine the aetiology, pathophysiology and the most appropriate strategies for prevention and management of hypertensive crisis. [ABSTRACT FROM AUTHOR]

Cardiovascular disease is a global public health problem. The management of cardiovascular emergencies is urgent due to the immediate life-threat.. Indeed, cardiovascular emergencies are responsible for 12 million deaths a year worldwide. In sub-Saharan Africa, its prevalence and burden are still poorly understood. Our study aimed to determine the prevalence and etiologies of cardiovascular emergencies. Material and methods: We conducted a 12-month prospective study from May 1st, 2014 to April 30th, 2015 at the Emergency Department of CHU Gabriel Touré, Bamako. It Included all patients aged ≥ 15 years old (y.o) hospitalized for cardiovascular emergency during the study period. The data were collected in a questionnaire and analyzed with EPI - info French version 6.04. Results: During this study, we collected 510 cases of cardiovascular emergency from 21600 ER admission, a prevalence of 1.2%.The average age was 57.07y.o ± 17.17. The female gender predominated with 57.3% with a sex ratio of 0.7. Patients had a low socio-economic status in 62.6% with 33% cases of unemployment. .Patients arrived in a taxi in 71.2% of the cases and they came right at the onset of the symptoms between 8 P.M and 12 A.M.28.7%Dyspnea was the most frequent reason for consultation with 23.7%. High blood pressure (HTA) was the most common cardiovascular risk factor with 54 % (Table I).Stroke was the most common diagnosis with 51.4% followed by global heart failure (15.1%) and coronary syndrome (10.1%) (Table II). The overall mortality rate was 23.3% (Table III). Conclusion: The frequency and burden of cardiovascular emergencies are still underestimated due to the lack or scarcity of diagnostic tools. [ABSTRACT FROM AUTHOR]

Background and aims Circulating endothelial microparticles (EMPs) are increased in arterial hypertension. The role of physicomechanical factors that may induce EMP release in vivo is still unknown. We studied the relationship of EMPs and physicomechanical factors in stable arterial hypertension and hypertensive emergencies, and investigated the pattern of EMP release after mechanical endothelial injury. Methods In a pilot study, 41 subjects (50% hypertensives) were recruited. EMPs were discriminated by flow-cytometry (CD31 + /41 - , CD62e + , CD144 + ). Besides blood pressure measurements, pulse-wave-analysis was performed. Flow-mediated dilation (FMD), nitroglycerin-mediated dilation (NMD), and wall-shear-stress (WSS) were measured ultrasonographically in the brachial artery; microvascular perfusion by laser-Doppler (Clinicaltrials.gov: NCT02795377). We studied patients with hypertensive emergencies before and 4 h after BP lowering by urapidil (n = 12) and studied the release of EMPs due to mechanical endothelial injury after coronary angiography (n = 10). Results Hypertensives exhibited increased EMPs (CD31 + /41 - , CD144 + , CD62e + ) as compared to normotensives and EMPs univariately correlated with systolic BP (SBP), augmentation index, and pulse wave velocity and inversely with FMD. CD31 + /41 - -EMPs correlated with diameter and inversely with WSS and NMD. CD62e + and CD144 + -EMPs inversely correlated with microvascular function. During hypertensive emergency, only CD62e + and CD144 + -EMPs were further elevated and FMD was decreased compared to stable hypertensives. Blood pressure lowering decreased CD62e + and CD144 + -EMPs and increased FMD. CD31 + /41 — EMPs, diameter, and WSS remained unaffected. Similar to hypertensive emergency, catheter-related endothelial injury increased only CD144 + and CD62e + -EMPs. Conclusions EMP release in hypertension is complex and may involve both physicomechanical endothelial injury and activation (CD144 + , CD62e + ) and decreased wall shear stress (CD31 + /41 - ). [ABSTRACT FROM AUTHOR]

Background: Cilostazol has been associated with spontaneous reports of cardiovascular adverse events and serious bleeding. The objective of this study is to determine the relative risk of cardiovascular adverse events or haemorrhages in patients with peripheral artery disease treated with cilostazol in comparison to pentoxifylline users.Methods: Population-based cohort study including all individuals older than 40 who initiated cilostazol or pentoxifylline during 2009-2011 in SIDIAP database. The two treatment groups were matched through propensity score (PS).Results: Nine thousand one hundred twenty-nine patients met inclusion criteria and after PS matching, there were 2905 patients in each group. 76% of patients were men, with similar mean ages in both groups (68.8 for cilostazol and 69.4 for pentoxifylline). There were no differences in bleeding, cerebrovascular and cardiovascular events between both groups.Conclusions: Patients treated with cilostazol were different from those treated with pentoxifylline at baseline, so they were matched through PS. We did not find differences between treatment groups in the incidence of bleeding or cardiovascular and cerebrovascular events. Cilostazol should be used with precaution in elderly polymedicated patients. [ABSTRACT FROM AUTHOR]