Tiziano Lenzi

Effectiveness of loading oral flecainide for converting recent-onset atrial fibrillation to sinus rhythm in patients without organic heart disease or with only systemic hypertension

Sixty-two patients with recent-onset (less than or equal to 1 week) atrial fibrillation (New York Heart Association functional class 1 and 2) were randomized in a single-blind study to 1 of the following treatment groups: (1) flecainide (300 mg) as a single oral loading dose; or (2) amiodarone (5 mg/kg) as an intravenous bolus, followed by 1.8 g/day; or (3) placebo for the first 8 hours. Twenty-four-hour Holter recording was performed, and conversion to sinus rhythm at 3, 8, 12 and 24 hours was considered as the criterion of efficacy. Conversion to sinus rhythm was achieved within 8 hours (placebo-controlled period) in 20 of 22 patients (91%) treated with flecainide, 7 of 19 (37%) treated with amiodarone (p less than 0.001 vs flecainide), and 10 of 21 (48%) treated with placebo (p less than 0.01 vs flecainide). Resumption of sinus rhythm within 24 hours occurred in 21 of 22 patients (95%) with flecainide and in 17 of 19 (89%) with amiodarone (p = not significant). Mean conversion times were shorter for flecainide (190 +/- 147 minutes) than for amiodarone (705 +/- 418; p less than 0.001). No major side effects occurred. At Holter monitoring, a pause of 9.3 seconds was observed in 1 asymptomatic patient treated with flecainide. Phases of atrial flutter with a ventricular rate less than or equal to 150 beats/min were detected before sinus conversion in 1 patient receiving placebo and in 2 receiving flecainide.(ABSTRACT TRUNCATED AT 250 WORDS)

Proposal for the use in emergency departments of cardiac troponins measured with the latest generation methods in patients with suspected acute coronary syndrome without persistent ST-segment elevation.

Abstract The purpose of this document is to develop recommendations on the use of the latest generation of cardiac troponins in emergency room settings for the diagnosis of myocardial infarction in patients with suspected acute coronary syndrome (ACS) without persistent ST-segment elevation (NSTE-ACS). The main points which have been addressed reaching a consensus are represented by: Suitability and appropriateness of the terminology. Appropriateness of the request. Confirmation of the diagnosis of myocardial infarction (rule-in). Exclusion of the diagnosis of myocardial infarction (rule-out). Work method: Each point has been analyzed by taking into account the evidence presented in medical publications. Recommendations were developed using the criteria adopted by the European Society of Cardiology and the American Heart Association/American College of Cardiology (www.escardio.org/guidelines). Each point of the recommendation was submitted for validation to an external audit by a Group of Experts (named above).

Cardioversion of acute atrial fibrillation in the short observation unit: comparison of a protocol focused on electrical cardioversion with simple antiarrhythmic treatment

Background Direct current cardioversion (DCC) has been shown to be effective for the management of atrial fibrillation (AF) in the emergency department (ED). Pharmacological cardioversion was compared with a strategy including DCC on patients with uncomplicated, recent-onset (<48 h) AF managed in a short observation unit (SOU). Methods A prospective observational study was undertaken over a period of 13 months in two institutions. A DCC-centred protocol was applied to 171 AF cases in a hospital (DCC-cohort) and pharmacological cardioversion to 151 AF cases in another hospital (P-cohort). Patients remaining in AF after 24 h were admitted. The outcomes were rate of discharge in sinus rhythm, length of stay in the ED-SOU, rate of hospitalisation and complications of treatment. Data collected were analysed according to Student t test and χ2 statistics. Results Discharge in sinus rhythm was achieved in 159/171 cases in the DCC-cohort and 77/151 cases in the P-cohort (93% vs 51%; number needed to treat (NNT) 2.4; 95% CI 2.0 to 3.1, p<0.001), whereas mean length of stay was 7+7 h in the DCC-cohort and 9+6 h in the P-cohort (p=0.43). Eleven cases from the DCC-cohort and 67 from the P-cohort were admitted (admission rate 6% vs 44%; NNT 2.6; 95% CI 2.2 to 3.5, p<0.001). Three short-term complications occurred in the DCC-cohort and five in the P-cohort (2% vs 3%, p=0.59). Two strokes were registered in the DCC-cohort during 6-month follow-up (p undefined). Conclusions Electrical cardioversion of recent-onset AF in the SOU is safe, effective and reduces hospitalisations. Further studies are needed to identify the most cost-effective strategy for the management of AF patients in emergency settings.

Reliability and validity of an Italian four-level emergency triage system

Objectives To measure the reliability and predictive validity of a four-level triage system (I-4L). Methods This observational study was conducted in an urban hospital. Five nurses were randomly selected to assign a triage level to 246 paper scenarios, using the I-4L model. The I-4L model is a four-level triage system: urgency category (UC) 1 requires immediate response; UCs 2, 3 and 4 require assessment within 20, 60 and 120 min, respectively. Weighted κ statistics were used to measure the inter-rater and intrarater reliability of the triage tool and the validity of the model was assessed based on the accuracy in predicting admission and in predicting a reference standards triage code. Results The I-4L models inter-rater reliability was κ=0.73 (95% CI 0.67 to 0.79), and the intrarater reliability was κ=0.82 (95% CI 0.67 to 0.96). Its accuracy of triage rating for admission and for prediction of a reference standards triage code was good: 79% (95% CI 73% to 86%) and 93% (95% CI 89% to 96%), respectively. The percentages of patients admitted per triage level using the I-4L model was: 100% UC 1; 42% UC 2; 6% UC 3; and 2% UC 4. Conclusions The I-4L triage model shows a good inter-rater and intrarater reliability for rating triage acuity and for accuracy in patient admission and prediction of a reference standards triage code.

Cardioversion in atrial fibrillation. Focus on recent-onset atrial fibrillation.

Atrial fibrillation is the most common sustained arrhythmia encountered in clinical practice. Its prevalence is rising due to an increasing elderly population and the improvement in management of life-threatening diseases such as myocardial infarction and heart failure. Over the past few years effective non-pharmacological treatments, new antiarrhythmics drugs, and anticoagulants have been introduced. Regardless of rate-control or rhythm control strategy, adequate stroke prevention still remains a cornerstone in the treatment of this arrhythmia. This review aims to illustrate the main practical issues in the management of atrial fibrillation, focusing on patients with recent-onset and hemodynamically stable atrial fibrillation.

An unusual case of pneumonia

The consultant pneumologist of our hospital asked us to hospitalize a young woman with dry cough, fever and bilateral pulmonary infiltrates. The consultant tried ciprofloxacin, then ceftriaxone and finally chlarytromicin with netilmicin without clinical response. Worried about this clinical history, I told him to refer the patient to our Emergency Department (ED). So far in her course, the patient had been treated as an outpatient. On physical examination, she had a good general appearance, and was not dyspnoeic at rest. Body temperature was 38.2 C. She was a 32-year-old woman, nonsmoker and full-time worker. She had two successful normal term labours, and regular menses. She had been diagnosed with ulcerative colitis 4 months prior, and had rapidly achieved clinical remission with mesalazine (continued as maintenance treatment). Chest X-ray studies showed bilateral pulmonary infiltrates of the upper lobes, without pleural effusions or mediastinal enlargement (Fig. 1). Oxygen saturation was not impaired (97% in room air); standard blood chemistries were unremarkable, apart from nonspecific signs of inflammation (ESR 52 [normal up to 15], C-Reactive Protein 14.6 mg/dl [normal up to 1.1 mg/dl], WBC 6,300/mm [N 84%, L 11%, E 0.6 %, M 3.4%, B 0.5%], Hb 9.7 g/dl, RBC 3,770,000/mm, MCV 79 fl, MCHC 32.5 g/dl, PLT 461,000/mm). Search for anti-mycoplasma antibodies, urinary antigen for Legionella (serotype 1) as well as anti nuclear, anti DNA antibodies and ANCA (cytoplasmic and perinuclear) were negative. Pulmonary function tests showed only a mild impairment of diffusing capacity for carbon monoxide DLCO (74% of the predicted value). The high resolution computed tomography scan of the chest showed a significant upper bilateral interstitial lung involvement of mixed reticular‘ground-glass’ type, with neither cavitation, solid pulmonary nodules/consolidations nor mediastinal lymph node enlargement (Fig. 2). A dry cough did not allow us to collect sputum for a Gram’s stain and cultures. It was decided to suspend the administration of mesalazine because of the fact that in rare cases it can induce pulmonary interstitial cases resembling those of our case. We also decided to start steroids (6-methyl prednisolone 40 mg/die given parenterally). After 5 days of treatment, the cough and fever resolved completely. The patient was discharged 2 days later, to take 32 mg/die of methylprednisolone per os, with a planned follow up visit to our service scheduled 7 days later, and a fast track appointment to the university center for inflammatory bowel disease. Neither broncoscopy nor lung biopsy were done, due to the rapid clinical improvement that had followed the discontinuation of mesalazine. Corticosteroids were given for 1 month. The Chest X-ray study at the end of treatment showed the complete resolution of the infiltrates previously described (Fig. 3). Twenty months later the patient had no pulmonary symptoms. This case emphasizes that ‘interstitial pneumonitis’ is a clinical syndrome rather than a distinct clinical entity. In fact, interstitial lung disease can be seen with at least 100 different aetiologies (infective, genetic, medications -with nearly 200 drugs implicated, inhaled substances, connective tissue diseases). Moreover, the occurrence of any lung disease poses special problems in patients with inflammatory bowel diseases (IBD) such as Ulcerative Colitis and Crohn’s disease. A sub-clinical pulmonary function impairment is present in up to 40–60% of IBD patients, without radiological abnormalities [1, 2] whereas clinically P. Iannone (&) T. Lenzi Pronto Soccorso e Medicina d’Urgenza, DEA Ospedale S.M. della Scaletta, via Montericco 4, 40026 Imola, Bologna, Italy e-mail: primiann@libero.it

Severe symptomatic bradycardia after a dinner of spicy oleander soup

Cardiac glycosides similar to digoxin are produced by different plants in nature. Nerium oleander, commonly grown as an ornamental shrub, can be found worldwide in temperate countries. Intentional or accidental ingestion of any part of the plant can lead to clinically relevant intoxication. A 63-year-old woman came to the emergency department with acute dyspeptic symptoms after eating vegetable soup flavored with unfamiliar flowers she have collected herself. However, the electrocardiography (ECG) showed abnormalities that raised suspicions for an overdose of digoxin-like cardiac glycosides. The patient was not on treatment with digoxin and a careful anamnesis revealed that she had eaten oleander leaves. Digoxin specific Fab antibody fragments were administered for marked bradycardia that was not responding to atropine administration, after counseling with the reference toxicology center. The patient was also treated with activated charcoal and magnesium sulphate, intravenous fluids and pantoprazole. Four days later she was discharged as asymptomatic, with normal sinus rhythm. Emergency physicians should be aware of this type of poisoning, especially in cases with typical ECG alterations in patients not treated with digoxin and medical history of plants ingestion. Cardio-active glycosides are present in different plants, often used inappropriately, with potential toxic effects and harmful drug interactions.

Proposal for the use in emergency departments of cardiac troponins measured with the latest generation methods in patients with suspected acute coronary syndrome without persistent ST-segment elevation

The purpose of this document is to develop recommendations on the use of the latest generation of cardiac troponins in emergency room settings for the diagnosis of myocardial infarction in patients with suspected acute coronary syndrome without persistent ST-segment elevation (NSTE-ACS). The main points which have been addressed reaching a consensus are: i) suitability and appropriateness of the terminology; ii) appropriateness of the request; iii) confirmation of the diagnosis of myocardial infarction (rule-in); iv) exclusion of the diagnosis of myocardial infarction (rule-out). Each point has been analyzed by taking into account the evidence presented in medical publications. Recommendations were developed using the criteria adopted by the European Society of Cardiology and the American Heart Association/American College of Cardiology. Each point of the recommendation was submitted for validation to an external audit by a Group of Experts (named above).

Acute abdominal pain: emergency diagnosis and managing (Part I)

Acute abdominal pain is a medical challenge for emergency physician due to the variety of possible diagnosis, lack of diagnostic and treatment standard in emergency department and the need of a rapid patient management. It is of paramount importance to quickly rule out or diagnose life threatening clinical conditions as acute myocardial infarction or aortic abdominal aneurism rupture. A few more time is allowed to confirm other diseases that lead to major complications if left untreated as acute appendicitis, testicular torsion and acute pyelonefritis. While acute abdominal pain in the elderly reflect often surgical conditions, it has a benign origin in the majority of young patients who can be generally managed as out patient, after a short clinical observation, with a diagnosis at discharge of non specific abdominal pain. The reason for the development of practical clinical pathways for patient with acute abdominal pain is to facilitate physician in differentiating patient who need hospital admission or a short intensive observation from those who can be safely discharged home.

Acute abdominal pain: emergency diagnosis and treatment (Part II)

Acute abdominal pain is a medical challenge for emergency physician due to the variety of possible diagnosis, lack of diagnostic and treatment standard in emergency department and the need of a rapid patient management. It is of paramount importance to quickly rule out or diagnose life threatening clinical conditions as acute myocardial infarction or aortic abdominal aneurism rupture. A few more time is allowed to confirm other diseases that lead to major complications if left untreated as acute appendicitis, testicular torsion and acute pyelonefritis. While acute abdominal pain in the elderly reflect often surgical conditions, it has a benign origin in the majority of young patients who can be generally managed as out patient, after a short clinical observation, with a diagnosis at discharge of non specific abdominal pain. The reason for the development of practical clinical pathways for patient with acute abdominal pain is to facilitate physician in differentiating patient who need hospital admission or a short intensive observation from those who can be safely discharged home.