Zohair Al Aseri

CRP levels are higher in patients with ST elevation than non-ST elevation acute coronary syndrome.

FUNDAMENTO: Hay gran interes en el uso de proteina C-reactiva de alta sensibilidad (PCR-as) para evaluacion de riesgo. Altos niveles de PCR-as en el comienzo del sindrome coronario agudo (SCA), antes de la necrosis tisular, puede ser un marcador sustituto para comorbilidades cardiovasculares. OBJETIVO: De esa forma, nuestro objetivo fue estudiar diferentes medidas de seguimiento de niveles de PCR-as en pacientes con SCA y comparar las diferencias entre infarto de miocardio sin elevacion del segmento ST (NSTEMI) con pacientes presentando elevacion del segmento ST (STEMI). METODOS: Este es un estudio observacional. De los 89 pacientes reclutados, 60 presentaban infarto agudo de miocardio (IAM). Tres niveles seriados de PCR-us, a nivel basal en la hospitalizacion antes de 12 horas despues del inicio de los sintomas, niveles de pico 36-48 horas despues de hospitalizacion y niveles de control despues de 4 a 6 semanas fueron analizados y comparados entre pacientes con (IAMCSST) y sin supradesnivel del segmento ST (IAMSSST). RESULTADOS: Pacientes con IAMCSST tenian IMC significativamente mas alta cuando fueron comparados con pacientes IAMSSST. Los niveles de creatinoquinasa fraccion MB (CK-MB) y aspartato aminotransferasa (AST) eran significativamente mas altos en pacientes con IAMCSST cuando fueron comparados con pacientes con IAMSSST (p<0,05). Los niveles de PCR a nivel basal y en el control no difirieron de forma significativa entre los dos grupos (p= 0,2152 y p=0,4686 respectivamente). Hubo una diferencia significativa en los niveles de pico de PCR entre los dos grupos. En el grupo de pacientes con IAMCSST los niveles fueron significativamente mas altos cuando fueron comparados a los pacientes con IAMSSST (p=0,0464). CONCLUSION: Pacientes con IAMCSST presentan picos significativamente mas elevados de PCR cuando son comparados a pacientes IAMSSST. Esos datos sugieren que el proceso inflamatorio tiene un papel independiente en la patogenesis del infarto de miocardio. De esa forma, los niveles de PCR pueden ayudar en la estratificacion de riesgo despues del infarto de miocardio.BACKGROUND There is intense interest in the use of high-sensitivity C-reactive protein (hsCRP) for risk assessment. Elevated hsCRP concentrations early in acute coronary syndrome (ACS), prior to the tissue necrosis, may be a surrogate marker for cardiovascular co-morbidities. OBJECTIVE Therefore we aimed to study different follow up measurements of hsCRP levels in acute coronary syndrome patients and to compare the difference between non-ST elevation myocardial infarction (NSTEMI) and ST myocardial infarction (STEMI) patients. METHODS This is an observational study. Of the 89 patients recruited 60 patients had acute myocardial infarction (AMI). Three serial hsCRP levels at baseline on admission to hospital before 12 hours of symptom onset, peak levels at 36-48 hours and follow up levels after 4-6 weeks were analyzed and compared between non-ST elevation AMI and ST elevation AMI. RESULTS STEMI patients had significantly higher BMI compared to NSTEMI patients. Creatine kinase myocardial bound (CKMB) and Aspartate aminotransferase (AST) levels were significantly higher in STEMI patients compared to NSTEMI patients (p<0.05). CRP levels at baseline and at follow up did not significantly differ between the two groups (p = 0.2152, p = 0.4686 respectively). There was a significant difference regarding peak CRP levels between the two groups, as STEMI patients had significantly higher peak CRP levels compared to NSTEMI patients (p = 0.0464). CONCLUSION STEMI patients have significantly higher peak CRP levels compared to NSTEMI patients. These data suggest that inflammatory processes play an independent role in the pathogenesis of myocardial infarction. Thus, CRP assessment may assist in risk stratification after myocardial infarction.

Patient and System-Related Delays of Emergency Medical Services Use in Acute ST-Elevation Myocardial Infarction: Results from the Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps)

Background Little is known about Emergency Medical Services (EMS) use and pre-hospital triage of patients with acute ST-elevation myocardial infarction (STEMI) in Arabian Gulf countries. Methods Clinical arrival and acute care within 24 h of STEMI symptom onset were compared between patients transferred by EMS (Red Crescent and Inter-Hospital) and those transferred by non-EMS means. Data were retrieved from a prospective registry of 36 hospitals in 6 Arabian Gulf countries, from January 2014 to January 2015. Results We enrolled 2,928 patients; mean age, 52.7 (SD ±11.8) years; 90% men; and 61.7% non-Arabian Gulf citizens. Only 753 patients (25.7%) used EMS; which was mostly via Inter-Hospital EMS (22%) rather than direct transfer from the scene to the hospital by the Red Crescent (3.7%). Compared to the non-EMS group, the EMS group was more likely to arrive initially at a primary or secondary health care facility; thus, they had longer median symptom-onset-to-emergency department arrival times (218 vs. 158 min; p˂.001); they were more likely to receive primary percutaneous coronary interventions (62% vs. 40.5%, p = 0.02); they had shorter door-to-needle times (38 vs. 42 min; p = .04); and shorter door-to-balloon times (47 vs. 83 min; p˂.001). High EMS use was independently predicted mostly by primary/secondary school educational levels and low or moderate socioeconomic status. Low EMS use was predicted by a history of angina and history of percutaneous coronary intervention. The groups had similar in-hospital deaths and outcomes. Conclusion Most acute STEMI patients in the Arabian Gulf region did not use EMS services. Improving Red Crescent infrastructure, establishing integrated STEMI networks, and launching educational public campaigns are top health care system priorities.

Níveis de PCR são maiores em pacientes com síndrome coronariana aguda e supradesnivelamento do segmento ST do que em pacientes sem supradesnivelamento do segmento ST

FUNDAMENTO: Hay gran interes en el uso de proteina C-reactiva de alta sensibilidad (PCR-as) para evaluacion de riesgo. Altos niveles de PCR-as en el comienzo del sindrome coronario agudo (SCA), antes de la necrosis tisular, puede ser un marcador sustituto para comorbilidades cardiovasculares. OBJETIVO: De esa forma, nuestro objetivo fue estudiar diferentes medidas de seguimiento de niveles de PCR-as en pacientes con SCA y comparar las diferencias entre infarto de miocardio sin elevacion del segmento ST (NSTEMI) con pacientes presentando elevacion del segmento ST (STEMI). METODOS: Este es un estudio observacional. De los 89 pacientes reclutados, 60 presentaban infarto agudo de miocardio (IAM). Tres niveles seriados de PCR-us, a nivel basal en la hospitalizacion antes de 12 horas despues del inicio de los sintomas, niveles de pico 36-48 horas despues de hospitalizacion y niveles de control despues de 4 a 6 semanas fueron analizados y comparados entre pacientes con (IAMCSST) y sin supradesnivel del segmento ST (IAMSSST). RESULTADOS: Pacientes con IAMCSST tenian IMC significativamente mas alta cuando fueron comparados con pacientes IAMSSST. Los niveles de creatinoquinasa fraccion MB (CK-MB) y aspartato aminotransferasa (AST) eran significativamente mas altos en pacientes con IAMCSST cuando fueron comparados con pacientes con IAMSSST (p<0,05). Los niveles de PCR a nivel basal y en el control no difirieron de forma significativa entre los dos grupos (p= 0,2152 y p=0,4686 respectivamente). Hubo una diferencia significativa en los niveles de pico de PCR entre los dos grupos. En el grupo de pacientes con IAMCSST los niveles fueron significativamente mas altos cuando fueron comparados a los pacientes con IAMSSST (p=0,0464). CONCLUSION: Pacientes con IAMCSST presentan picos significativamente mas elevados de PCR cuando son comparados a pacientes IAMSSST. Esos datos sugieren que el proceso inflamatorio tiene un papel independiente en la patogenesis del infarto de miocardio. De esa forma, los niveles de PCR pueden ayudar en la estratificacion de riesgo despues del infarto de miocardio.BACKGROUND There is intense interest in the use of high-sensitivity C-reactive protein (hsCRP) for risk assessment. Elevated hsCRP concentrations early in acute coronary syndrome (ACS), prior to the tissue necrosis, may be a surrogate marker for cardiovascular co-morbidities. OBJECTIVE Therefore we aimed to study different follow up measurements of hsCRP levels in acute coronary syndrome patients and to compare the difference between non-ST elevation myocardial infarction (NSTEMI) and ST myocardial infarction (STEMI) patients. METHODS This is an observational study. Of the 89 patients recruited 60 patients had acute myocardial infarction (AMI). Three serial hsCRP levels at baseline on admission to hospital before 12 hours of symptom onset, peak levels at 36-48 hours and follow up levels after 4-6 weeks were analyzed and compared between non-ST elevation AMI and ST elevation AMI. RESULTS STEMI patients had significantly higher BMI compared to NSTEMI patients. Creatine kinase myocardial bound (CKMB) and Aspartate aminotransferase (AST) levels were significantly higher in STEMI patients compared to NSTEMI patients (p<0.05). CRP levels at baseline and at follow up did not significantly differ between the two groups (p = 0.2152, p = 0.4686 respectively). There was a significant difference regarding peak CRP levels between the two groups, as STEMI patients had significantly higher peak CRP levels compared to NSTEMI patients (p = 0.0464). CONCLUSION STEMI patients have significantly higher peak CRP levels compared to NSTEMI patients. These data suggest that inflammatory processes play an independent role in the pathogenesis of myocardial infarction. Thus, CRP assessment may assist in risk stratification after myocardial infarction.

Marked Symptomatic Bradycardia Associated with Profound Hyperkalemia

Background and objectives: Hyperkalemia is a common disorder presents to Emergency Department (ED) with different type of presentations, one of them is cardiac dysrythmia which can be lethal if potassium level is not normalized quickly and cardiac cells stabilized by calcium in appropriate manner. We hypothesize that administration of calcium and potassium lowering drugs will prevent the need for aggressive intervention for patient with sever hyperkalemia and very slow heart rate with decrease level of consciousness. Design and setting: Prospective, patient presented to academic emergency department. Patient and method: On arrival to the emergency department, patient was confused with a lethargic mental status and pulse rate of 41 beat per minute. Blood samples were sent for immediate determination of venous blood gas (VBG) concentrations, which showed potassium concentration of 7.85 mmol/L. The patient was immediately started on hyperkalemia treatment including 2 g calcium chloride was administered intravenously (IV) over 5 minutes. The patient started to regain consciousness and recognize her family with 10 minutes of these treatments. Results: A repeat ECG showed atrial fibrillation, which is similar to the patient‘s baseline ECG before this admission. Repeat VBG results 90 minutes later showed pH 7.22, Pco2 39.8 mm Hg, Po2 26.5 mm Hg, HC03 15.9 mmol/L, and potassium 6.00 mmol/L. These interventions led to an almost immediate resolution of the sever bradycardia without the need for temporary cardiac pacing. Conclusion: Life-threatening hyperkalemia should be suspected in any patient with acute onset bradycardia who presents to the emergency department. Blood potassium concentration should be determined immediately by rapid point-of-care tests for an early diagnosis and appropriate medical treatment. Sufficient agreement is found in potassium levels obtained from a chemistry laboratory analyzer and a VBG analyzer.

Comparison of Observer Performance between Emergency Physicians at Different Level of Experience using Digital Imaging

Objectives: Digital radiology is relatively new technology that allows the examiner a number of advantages. The objective of this study is to evaluate the efficacy of digital chest radiography using plain expiratory and inspiratory images to detect Pneumothorax and comparison of observer performance between residents and experienced Emergency Department (ED) physicians. Methods: Plain digital images of chest radiographs containing expiratory and inspiratory views, requested to exclude Pneumothorax from January 2000 to December 2003 were included. All images were reviewed independently by three experienced ED physician and three ED residents. The physicians were asked to decide on the presence or absence of a Pneumothorax, its site, size and its percentage of occupying area. The physician’s reports were recorded and compared with reports of consultant radiologists as a standard. Results: A total of 252 sets of inspiratory and expiratory films were ordered. Of the 118 pairs that met the inclusion and exclusion criteria, 76 pairs (64.4%) were positive for Pneumothorax using the standard consultant radiologist’s reports. Overall sensitivity was 72.6% (CI ± 4.2) for inspiratory and 80.0% (CI ± 3.7) for expiratory films (P=0.001), with a specificity of 69.4% (CI ± 4.6) for inspiratory and 73.1% (CI ± 4.8) for expiratory films (P=0.12). The kappa for agreement was 0.65, 0.52, and 0.32 for the presence of Pneumothoraces, their size (small, medium, or large), and their percentage of occupying the area of pleural cavity respectively. Conclusion: Expiratory images on a digital viewer are more sensitive than inspiratory images for detecting Pneumothoraces, and this difference is decreased with expert physician’s review. The agreement was poor when a percentage is used to describe the size of the Pneumothorax occupying Pleural cavity.

Vital Indices to be used in Resuscitation of Patients with Shock in the Emergency Department Setting

Background: The outcome of shock depends on early intervention and management of patient’s arrival at the hospital. Managing these patients in the emergency department (ED) can be challenging because of the complex nature and various causes of the disease. This review discusses the indices that can be used by ED staff in approaching diagnosis and the management for shock particularly circulatory shock in the ED. Objectives: To review various indices which can be used by the ED physician with ease to diagnose and manage patients with shock. Data Sources: Medline search from 1970 to present plus cited reference studies and abstracts from available product literature. Selection criteria included published articles and abstracts comparing the accuracy of invasive and noninvasive hemodynamic monitors and relation of their use to patients outcome. Discussion: Shock is a critical condition brought on by failure of the circulatory system to maintain adequate tissue perfusion. In the busy and overcrowded arena of emergency department (ED) patient’s prolong stay is unavoidable. This common phenomenon in ED perspective inevitably necessitates tangible diagnostic and therapeutic interventions to attain hemodynamic stability of patients with shock that would otherwise be performed in the ICU. This article reviews the pathophysiology of shock, common indices to monitor hemodynamic (HD) and other methods that may be helpful to diagnose and manage shock within the “golden hours” to reduce the morbidity and mortality of shock. Conclusion: Early hemodynamic assessment using Goal directed resuscitation history, physical examination, vital signs, central venous pressure (CVP) and other indices should be used in combination by the ED physician to diagnose and manage shock patients successfully.

SHA 102. Tissue plasminogen activator and plasminogen activator inhibitor-1 levels in patients with acute myocardial infarction and unstable angina

<1.8 mmol/L was achieved in 32%, in contrast to 40% at follow-up (P < 0.044). Twenty-three percent of patients at baseline had their glycated hemoglobin <0.070, improved to 33% at follow-up (P < 0.004). Prescription of beta blockers declined from 97% at enrollment to 90% at follow-up (P < 0.002). Utilization of lipid lowering agents was 98% with no change after follow up (P= 1). Conclusion: Nurse-led CVDMP in KAMC was effective in controlling cardiovascular risk factors in patients with CAD and adheres to utilization of evidence based CAD medications.

Niveles de PCR son mayores en pacientes con síndrome coronario agudo y supradesnivel del segmento ST que en pacientes sin supradesnivel del segmento ST

FUNDAMENTO: Hay gran interes en el uso de proteina C-reactiva de alta sensibilidad (PCR-as) para evaluacion de riesgo. Altos niveles de PCR-as en el comienzo del sindrome coronario agudo (SCA), antes de la necrosis tisular, puede ser un marcador sustituto para comorbilidades cardiovasculares. OBJETIVO: De esa forma, nuestro objetivo fue estudiar diferentes medidas de seguimiento de niveles de PCR-as en pacientes con SCA y comparar las diferencias entre infarto de miocardio sin elevacion del segmento ST (NSTEMI) con pacientes presentando elevacion del segmento ST (STEMI). METODOS: Este es un estudio observacional. De los 89 pacientes reclutados, 60 presentaban infarto agudo de miocardio (IAM). Tres niveles seriados de PCR-us, a nivel basal en la hospitalizacion antes de 12 horas despues del inicio de los sintomas, niveles de pico 36-48 horas despues de hospitalizacion y niveles de control despues de 4 a 6 semanas fueron analizados y comparados entre pacientes con (IAMCSST) y sin supradesnivel del segmento ST (IAMSSST). RESULTADOS: Pacientes con IAMCSST tenian IMC significativamente mas alta cuando fueron comparados con pacientes IAMSSST. Los niveles de creatinoquinasa fraccion MB (CK-MB) y aspartato aminotransferasa (AST) eran significativamente mas altos en pacientes con IAMCSST cuando fueron comparados con pacientes con IAMSSST (p<0,05). Los niveles de PCR a nivel basal y en el control no difirieron de forma significativa entre los dos grupos (p= 0,2152 y p=0,4686 respectivamente). Hubo una diferencia significativa en los niveles de pico de PCR entre los dos grupos. En el grupo de pacientes con IAMCSST los niveles fueron significativamente mas altos cuando fueron comparados a los pacientes con IAMSSST (p=0,0464). CONCLUSION: Pacientes con IAMCSST presentan picos significativamente mas elevados de PCR cuando son comparados a pacientes IAMSSST. Esos datos sugieren que el proceso inflamatorio tiene un papel independiente en la patogenesis del infarto de miocardio. De esa forma, los niveles de PCR pueden ayudar en la estratificacion de riesgo despues del infarto de miocardio.BACKGROUND There is intense interest in the use of high-sensitivity C-reactive protein (hsCRP) for risk assessment. Elevated hsCRP concentrations early in acute coronary syndrome (ACS), prior to the tissue necrosis, may be a surrogate marker for cardiovascular co-morbidities. OBJECTIVE Therefore we aimed to study different follow up measurements of hsCRP levels in acute coronary syndrome patients and to compare the difference between non-ST elevation myocardial infarction (NSTEMI) and ST myocardial infarction (STEMI) patients. METHODS This is an observational study. Of the 89 patients recruited 60 patients had acute myocardial infarction (AMI). Three serial hsCRP levels at baseline on admission to hospital before 12 hours of symptom onset, peak levels at 36-48 hours and follow up levels after 4-6 weeks were analyzed and compared between non-ST elevation AMI and ST elevation AMI. RESULTS STEMI patients had significantly higher BMI compared to NSTEMI patients. Creatine kinase myocardial bound (CKMB) and Aspartate aminotransferase (AST) levels were significantly higher in STEMI patients compared to NSTEMI patients (p<0.05). CRP levels at baseline and at follow up did not significantly differ between the two groups (p = 0.2152, p = 0.4686 respectively). There was a significant difference regarding peak CRP levels between the two groups, as STEMI patients had significantly higher peak CRP levels compared to NSTEMI patients (p = 0.0464). CONCLUSION STEMI patients have significantly higher peak CRP levels compared to NSTEMI patients. These data suggest that inflammatory processes play an independent role in the pathogenesis of myocardial infarction. Thus, CRP assessment may assist in risk stratification after myocardial infarction.