Jennifer L. Martindale

Antidysrhythmic drug therapy for the termination of stable, monomorphic ventricular tachycardia: a systematic review

Objective We performed a systematic review of the literature to compare the efficacy of different drug therapies for the termination of stable, monomorphic ventricular tachycardia (VT). Methods We searched EMBASE, MEDLINE and Cochrane for trials from 1965 through July 2013 using a search strategy derived from the following clinical question in PICO format: Patients: Adults (≥18 years) with stable monomorphic VT; Intervention: Intravenous antidysrhythmic drug; Comparator: Intravenous lidocaine or amiodarone; Outcome: Termination of VT. For all drug comparisons, we calculated relative risks (RR; 95% CI) and number needed to treat (NNT, 95% CI) between drugs. We also evaluated the methodological quality of the studies. Results Our search yielded 219 articles by PubMed and 390 articles by EMBASE. 3 prospective studies (n=93 patients) and 2 retrospective studies (n=173 patients) met our inclusion and exclusion criteria. From the prospective studies, RR of VT termination of procainamide versus lidocaine was 3.7 (1.3–10.5); ajmaline versus lidocaine, RR=5.3 (1.4–20.5); and sotalol versus lidocaine, RR=3.9 (1.3–11.5). From the retrospective studies: procainamide versus lidocaine, RR=2.2 (1.2–4.0); and procainamide versus amiodarone RR=4.3 (0.8–23.6). All 5 reviewed studies had quality issues, including potential bias for randomisation and concealment. Conclusions Based on limited available evidence from small heterogeneous human studies, for the treatment of stable, monomorphic VT, procainamide, ajmaline and sotalol were all superior to lidocaine; amiodarone was not more effective than procainamide.

Clinical and Research Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society for Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group

Management approaches for patients in the emergency department (ED) who present with acute heart failure (AHF) have largely focused on intravenous diuretics. Yet, the primary pathophysiologic derangement underlying AHF in many patients is not solely volume overload. Patients with hypertensive AHF (H-AHF) represent a clinical phenotype with distinct pathophysiologic mechanisms that result in elevated ventricular filling pressures. To optimize treatment response and minimize adverse events in this subgroup, we propose that clinical management be tailored to a conceptual model of disease that is based on these mechanisms. This consensus statement reviews the relevant pathophysiology, clinical characteristics, approach to therapy, and considerations for clinical trials in ED patients with H-AHF.

β-Blockers versus calcium channel blockers for acute rate control of atrial fibrillation with rapid ventricular response: a systematic review.

This is a systematic review of the literature to compare the efficacy of calcium channel blockers to &bgr;-blockers for acute rate control of atrial fibrillation with rapid ventricular response in the emergency department setting. PubMed, EMBASE, and the Cochrane Registry were searched. Relative risk (95% confidence interval) was calculated between drugs and methodological quality of included studies was evaluated. Of the 1003 studies yielded by our initial search, two met inclusion criteria and provided sufficient data. These were randomized double-blinded studies (n=92) comparing intravenous diltiazem with intravenous metoprolol. The combined relative risk of acute rate control by diltiazem versus metoprolol was 1.8 (95% confidence interval 1.2–2.6). On the basis of the paucity of available evidence, diltiazem may be more effective than metoprolol in achieving rapid rate control, but high-quality randomized studies are needed.

Serial Sonographic Assessment of Pulmonary Edema in Patients With Hypertensive Acute Heart Failure

Objective measures of clinical improvement in patients with acute heart failure (AHF) are lacking. The aim of this study was to determine whether repeated lung sonography could semiquantitatively capture changes in pulmonary edema (B‐lines) in patients with hypertensive AHF early in the course of treatment.

Resolution of sonographic B-lines as a measure of pulmonary decongestion in acute heart failure

Objective noninvasive measures of dyspnea in patients with acute heart failure are lacking. In this review, we describe lung ultrasound as a tool to estimate the degree of pulmonary congestion in patients presenting with acute heart failure and to monitor therapeutic efficacy. Serial semiquantitative measures of sonographic B-lines in acute heart failure patients can be converted to pulmonary edema scores obtained at admission and hospital discharge. These scores provide prognostic information for short-term clinical outcomes. Lung ultrasound has the potential to measure changes in pulmonary edema during acute heart failure management and improve risk stratification.

Clinical and Research Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society of Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group

Management approaches for patients in the emergency department (ED) who present with acute heart failure (AHF) have largely focused on intravenous diuretics. Yet, the primary pathophysiologic derangement underlying AHF in many patients is not solely volume overload. Patients with hypertensive AHF (H-AHF) represent a clinical phenotype with distinct pathophysiologic mechanisms that result in elevated ventricular filling pressures. To optimize treatment response and minimize adverse events in this subgroup, we propose that clinical management be tailored to a conceptual model of disease based on these mechanisms. This consensus statement reviews the relevant pathophysiology, clinical characteristics, approach to therapy, and considerations for clinical trials in ED patients with H-AHF.

Recurrent concerns for child abuse: Repeated consultations by a subspecialty child abuse team

Physically abused children may be repeatedly reported to child protection services and undergo multiple medical evaluations. Less is known about recurrent evaluations by hospital-based child abuse teams for possible abuse. The objectives of this study were to determine the frequency of repeated consultations by child abuse teams and to describe this cohort in terms of injury pattern, perceived likelihood of abuse, disposition plan, and factors related to repeat consultation. This was a prospectively planned, secondary analysis of data from the Examining Siblings to Recognize Abuse (ExSTRA) research network. Subjects included children younger than 10 years of age who were referred to child abuse subspecialty teams at one of 20 U.S. academic centers. Repeat consultations occurred in 101 (3.5%; 95% CI 2.9-4.2%) of 2890 subjects. The incidence of death was 4% (95% CI 1-9%) in subjects with repeated consults and 3% (95% CI 2-3%) in subjects with single consults. Perceived likelihood of abuse from initial to repeat visit remained low in 33% of subjects, remained high in 24.2% of subjects, went from low to high in 16.5%, and high to low in 26.4% of subjects. Themes identified among the subset of patients suspected of repeated abuse include return to the same environment, failure to comply with a safety plan, and abuse in foster care. Repeated consultation by child abuse specialists occurs for a minority of children. This group of children may be at higher risk of subsequent abuse and may represent an opportunity for quality improvement.