Bruno Riou

Guideline-concordant administration of prothrombin complex concentrate and vitamin K is associated with decreased mortality in patients with severe bleeding under vitamin K antagonist treatment (EPAHK study)

IntroductionIn vitamin K antagonist (VKA)-treated patients with severe hemorrhage, guidelines recommend prompt VKA reversal with prothrombin complex concentrate (PCC) and vitamin K. The aim of this observational cohort study was to evaluate the impact of guideline concordant administration of PCC and vitamin K on seven-day mortality.MethodsData from consecutive patients treated with PCC were prospectively collected in 44 emergency departments. Type of hemorrhage, coagulation parameters, type of treatment and seven-day mortality mortality were recorded. Guideline-concordant administration of PCC and vitamin K (GC-PCC-K) were defined by at least 20 IU/kg factor IX equivalent PCC and at least 5 mg of vitamin K performed within a predefined time frame of eight hours after admission. Multivariate analysis was used to assess the effect of appropriate reversal on seven-day mortality in all patients and in those with intracranial hemorrhage (ICH).ResultsData from 822 VKA-treated patients with severe hemorrhage were collected over 14 months. Bleeding was gastrointestinal (32%), intracranial (32%), muscular (13%), and “other” (23%). In the whole cohort, seven-day mortality was 13% and 33% in patients with ICH. GC-PCC-K was performed in 38% of all patients and 44% of ICH patients. Multivariate analysis showed a two-fold decrease in seven-day mortality in patients with GC-PCC-K (odds ratio (OR)u2009=u20092.15 (1.20 to 3.88); Pu2009=u20090.011); this mortality reduction was also observed when only ICH was considered (ORu2009=u20093.23 (1.53 to 6.79); Pu2009=u20090.002).ConclusionsGuideline-concordant VKA reversal with PCC and vitamin K within eight hours after admission was associated with a significant decrease in seven-day mortality.

Natriuretic peptide testing in EDs for managing acute dyspnea: a meta-analysis ☆

PURPOSESnThe aim of the study was to assess the usefulness of systematic natriuretic peptide testing in the management of patients presenting with acute dyspnea to emergency departments (EDs).nnnMETHODSnWe performed a systematic review and meta-analysis of randomized controlled trials assessing the usefulness of B-type natriuretic peptide (BNP) or its N-terminal fragment (NT-proBNP) in the management of patients presenting with dyspnea into ED. We searched Medline, Embase, and conference proceedings without restriction on neither language nor publication year. Selection of studies, data collection, and assessment of risk of bias were performed by 2 reviewers independently and in duplicate. Outcomes included hospital admission rate, time to discharge, and length of hospital stay, mortality and rehospitalization rates, and total direct medical costs. Combined risk ratios were estimated using fixed or random effects model. Duration and cost data were not combined.nnnFINDINGSnFour randomized controlled trials, representing 2041 patients, were selected. In 4 trials, there was a tendency for hospital admission to be reduced in the intervention group (combined risk ratio, 0.95; 95% confidence interval, 0.89-1.01). Time to discharge was significantly reduced in 2 trials, whereas there was no significant reduction in hospital length of stay in 3 trials. There was no significant effect on in-hospital and 30-day mortality rates or rehospitalization rates (3 trials reporting each outcome). Two trials found significant reduction in direct costs.nnnCONCLUSIONSnThe current evidence remains inconclusive on whether systematic natriuretic peptide testing is useful for the management of patients presenting to ED with acute dyspnea.