Acute care bundles should be used for patients with intracerebral haemorrhage: An expert consensus statement.

Purpose: Intracerebral haemorrhage (ICH) is the most devastating form of stroke and a major cause of disability. Clinical trials of individual therapies have failed to definitively establish a specific beneficial treatment. However, clinical trials of introducing care bundles, with multiple therapies provided in parallel, appear to clearly reduce morbidity and mortality.

Management of Severe Bleeding in Patients Treated With Oral Anticoagulants: Proceedings Monograph From the Emergency Medicine Cardiac Research and Education Group-International Multidisciplinary Severe Bleeding Consensus Panel October 20, 2018.

In this Emergency Medicine Cardiac Research and Education Group (EMCREG)-International Proceedings Monograph from the October 20, 2018, EMCREG-International Multidisciplinary Consensus Panel on Management of Severe Bleeding in Patients Treated With Oral Anticoagulants held in Orlando, FL, you will find a detailed discussion regarding the treatment of patients requiring anticoagulation and the reversal of anticoagulation for patients with severe bleeding. For emergency physicians, critical care physicians, hospitalists, cardiologists, internists, surgeons, and family physicians, the current approach and disease indications for treatment with anticoagulants such as coumadin, factor IIa, and factor Xa inhibitors are particularly relevant. When a patient treated with anticoagulants presents to the emergency department, intensive care unit, or operating room with severe, uncontrollable bleeding, achieving rapid, controlled hemostasis is critically important to save the patient's life.

Association of Early Stress Testing with Outcomes for Emergency Department Evaluation of Suspected Acute Coronary Syndrome.

Background: Professional society guidelines suggest early stress testing (within 72 hours) after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS). However, there is increasing concern that current practice results in over-testing without evidence of benefit. We test the hypothesis that early stress testing improves outcomes.

Sonographic markers associated with adverse neonatal outcomes among fetuses with gastroschisis: an 11-year, single-center review.

Background: Gastroschisis complicates 1 in 2000 births and is readily identifiable during prenatal ultrasound scans. Outcomes in fetuses that are affected by gastroschisis vary widely from stillbirth or neonatal death to uncomplicated surgical correction, which makes prenatal counseling challenging.

Objective: The goal of our study was to identify sonographic markers that are associated with perinatal death and morbidity that include significant bowel injury, necrotizing enterocolitis, and the need for bowel resection in fetuses with gastroschisis.

Polyvascular disease and long-term cardiovascular outcomes in older patients with non-ST-segment-elevation myocardial infarction.

Background: The impact of polyvascular disease (peripheral arterial disease [PAD] and cerebrovascular disease [CVD]) on long-term cardiovascular outcomes among older patients with acute myocardial infarction has not been well studied.

Methods And Results: Patients with non-ST-segment-elevation myocardial infarction aged ≥65 years from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) registry who survived to hospital discharge were linked to longitudinal data from the Centers for Medicare & Medicaid Services (n=34 205). All patients were presumed to have coronary artery disease (CAD) and were classified into the following 4 groups: 10.

Self-reported cocaine use, emergency physician testing and outcomes in suspected acute coronary syndromes: a nested matched case-control study.

Objectives: The primary purpose was to compare the odds of acute coronary syndrome-pertinent diagnostic testing between self-reported cocaine users and non-users at the turn of the century. The secondary purpose was to compare the odds of acute coronary syndrome outcomes between cocaine users and non-users.

Design: Nested matched case-control study using data from the Internet Tracking Registry of Acute Coronary Syndromes.

Ground emergency medical services requests for helicopter transfer of ST-segment elevation myocardial infarction patients decrease medical contact to balloon times in rural and suburban settings.

Objectives:   ST-segment elevation myocardial infarction (STEMI) care is time-dependent. Many STEMI patients require interhospital helicopter transfer for percutaneous coronary intervention (PCI) if ground emergency medical services (EMS) initially transport the patient to a non-PCI center. This investigation models potential time savings of ground EMS requests for helicopter EMS (HEMS) transport of a STEMI patient directly to a PCI center, rather than usual transport to a local hospital with subsequent transfer.

Risk scores for patients with chest pain: evaluation in the emergency department.

Chest pain is a common reason for presentation to the emergency department (ED). Absolute criteria for Acute Coronary Syndrome without ST elevation (NSTE-ACS) are lacking. An acute coronary syndrome (ACS) needs to be distinguished from a variety of other cardiac and non-cardiac diseases that may cause chest pain.

Predicting long-term mortality in older patients after non-ST-segment elevation myocardial infarction: the CRUSADE long-term mortality model and risk score.

Objectives: We sought to develop a long-term mortality risk prediction model and a simplified risk score for use in older patients with non-ST-segment elevation myocardial infarction (NSTEMI).

Background: Limited data are available regarding long-term mortality rates and concomitant risk predictors after acute myocardial infarction in contemporary community practice.

Methods: From the CRUSADE registry, a total of 43,239 (NSTEMI) patients aged ≥65 years treated at 448 hospitals in the United States from 2003 to 2006 were linked to Centers for Medicare and Medicaid Services data to track longitudinal all-cause mortality (median follow-up 453 days).

Predictors of 30-day cardiovascular events in patients with prior percutaneous coronary intervention or coronary artery bypass grafting.

Objectives: Risk stratification of patients with potential acute coronary syndrome (ACS) is difficult. Patients with prior revascularization are considered higher risk, but they can also have symptoms from noncardiac causes. This study evaluated whether the presenting clinical characteristics were predictive of an increased risk of 30-day cardiovascular events in patients with prior revascularization presenting to the emergency department (ED) with symptoms of potential ACS.

Lipid-lowering intensification and low-density lipoprotein cholesterol achievement from hospital admission to 1-year follow-up after an acute coronary syndrome event: results from the Medications ApplIed aNd SusTAINed Over Time (MAINTAIN) registry.

Background: Current American College of Cardiology/American Heart Association guidelines recommend initiation or intensification of statin therapy to achieve low-density lipoprotein cholesterol (LDL-C) goals after an acute coronary syndrome (ACS), yet little is known about the actual practice of intensifying lipid-lowering (LL) therapy and LDL-C achievement from hospital admission to 1-year follow-up.

Methods: The MAINTAIN registry enrolled ACS patients from January 2006 through September 2007, collecting data on statin formulation, dose, and lipid profiles at both baseline and 12 months. Statin intensity (estimated LDL-C lowering) was categorized by formulation and dose as either moderate (<40%) or intensive (≥40%).

Changes in glycoprotein IIb/IIIa inhibitor excess dosing with site-specific safety feedback in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) initiative.

Background: Glycoprotein (GP) IIb/IIIa inhibitors can improve outcomes in patients with non-ST-segment elevation acute coronary syndromes but raise the risk of bleeding, particularly if dosed in excess. The impact of GP IIb/IIIa dosing feedback on safety and major bleeding is unknown.

Methods: Glycoprotein IIb/IIIa dosing feedback was added to the CRUSADE quarterly site reports in the first quarter of 2006.

Reperfusion is delayed beyond guideline recommendations in patients requiring interhospital helicopter transfer for treatment of ST-segment elevation myocardial infarction.

Study Objective: Early reperfusion portends better outcomes for ST-segment elevation myocardial infarction (STEMI) patients. This investigation estimates the proportions of STEMI patients transported by a hospital-based helicopter emergency medical services (EMS) system who meet the goals of 90-minute door-to-balloon time for percutaneous coronary intervention or 30-minute door-to-needle time for fibrinolysis.

Methods: This was a multicenter, retrospective chart review of STEMI patients flown by a hospital-based helicopter service in 2007.

Influence of transfer-in rates on quality of care and outcomes at receiving hospitals in patients with non-ST-segment elevation myocardial infarction.

Background: Patients with non-ST-segment elevation myocardial infarction (NSTEMI) are frequently transferred to tertiary hospitals for angiography and/or revascularization from hospitals lacking such capabilities. Given that patients who undergo invasive cardiac procedures are younger and have fewer comorbidities compared with those managed medically, the relative proportion of transfer-in patients at tertiary hospitals may influence comparisons of quality and guidelines adherence.

Methods: We evaluated 142,092 NSTEMI patients treated at 396 revascularization-capable sites in the CRUSADE National Quality Improvement Initiative from 2001 to 2006.

Outcomes associated with small changes in normal-range cardiac markers.

Introduction: Troponin concentrations rising above an institutional cutpoint are used to define acute myocardial necrosis, yet it is uncertain what outcomes are associated with fluctuations in troponin that do not exceed this level. We evaluate the association between troponin fluctuations below an institutional upper limit of normal and acute coronary syndrome (ACS).

Materials And Methods: This was a post hoc analysis of the Internet tracking registry of ACS (i*trACS), which describes patients presenting to emergency departments (EDs) with suspected ACS across the spectrum of risk.

Implications and reasons for the lack of use of reperfusion therapy in patients with ST-segment elevation myocardial infarction: findings from the CRUSADE initiative.

Background: Prompt reperfusion for patients with ST-segment elevation myocardial infarction (STEMI) is a class I guideline recommendation and has been shown to reduce mortality. However, many STEMI patients in contemporary practice still do not receive any form of reperfusion therapy.

Methods: We evaluated 8,578 patients with STEMI from 226 US hospitals participating in the CRUSADE quality improvement initiative from September 2004 to December 2006 to determine the proportion of eligible patients who received an attempt at reperfusion therapy and factors associated with lack of reperfusion among patients without a contraindication to reperfusion.

Influence of clinical trial participation on subsequent antithrombin use.

Background: Results from the Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial showed that the low-molecular-weight heparin (LMWH) enoxaparin was non-inferior compared with unfractionated heparin (UFH) in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) managed invasively.

Hypothesis: We explored the influence of SYNERGY trial site participation on subsequent patterns of heparin use for NSTE-ACS patients treated in routine practice.

Methods: We examined temporal patterns of LMWH use compared with UFH use among 122 764 patients with NSTE-ACS enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative between January 1, 2002 and June 30, 2006, to determine whether site participation in SYNERGY influenced the type of heparin used before and after publication of the SYNERGY results in July 2004.

Temporal changes in the use of drug-eluting stents for patients with non-ST-Segment-elevation myocardial infarction undergoing percutaneous coronary intervention from 2006 to 2008: results from the can rapid risk stratification of unstable angina patients supress ADverse outcomes with early implementation of the ACC/AHA guidelines (CRUSADE) and acute coronary treatment and intervention outcomes network-get with the guidelines (ACTION-GWTG) registries.

Background: The risks of late stent thrombosis with drug-eluting stents (DES) were intensely debated after the presentation of a number of studies highlighting this issue in September 2006. We evaluated trends in the use of DES for patients with non-ST-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) from 2006 to 2008.

Methods And Results: Temporal patterns of DES use were examined among non-ST-elevation myocardial infarction patients in the Can Rapid risk stratification of Unstable angina patients Supress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE; January 2006 to December 2006) and Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (ACTION-GWTG; January 2007 to June 2008) registries to determine how practice patterns changed for patients with acute myocardial infarction undergoing PCI.

Use of guidelines-recommended management and outcomes among women and men with low-level troponin elevation: insights from CRUSADE.

Background: Troponin elevation above the upper limit of normal (ULN) is diagnostic of myocardial infarction, but interpretation of "gray-zone" troponin elevations (1 to 1.5x ULN) remains uncertain. Using the CRUSADE database, we explored relationships between sex and treatment and outcomes among patients with troponin 1 to 1.