MSCT for ACS: Good in Stressful Situations?

For the final journal club of the year, Ravi picked an article from Goldstein (and others)  entitled, “A Randomized Controlled Trial of Multi-Sliced Coronary Computed Tomography for Evaluation of Acute Chest Pain” (available from the Journal of the American College of Cardiology, 2007 Vol 49, No. 8, pp863-871).

It’s not the definitive, practice-changing study we’re waiting for, but it draws upon previous work (such as JAMA 2005; 293:2471-8) estabilishing multi-slice CT coronary angiography as effective in diagnosing occlusion, and attempts to compare the safety, efficacy and efficiency of MSCT against established protocols.

Hypotension Makes for Poor Prognosis in Ischemic Stroke

This month in Journal Club, we continued our theme of prognostication papers as Corey reviewed two recent ones from Latha G. Stead’s group at Mayo.  One paper ran last year and is called “Initial Emergency Department Blood Pressure as Predictor of Survival After Acute Ischemic Stroke” (Neurology 2005, 65:1179:1183). The second paper is called “Impact of Acute Blood Pressure Variability on Ischemic Stroke Outcome” (Neurology 2006:66:1878-1881).

This is something I frankly hadn’t spent much time thinking about — all the emphasis in stroke guidelines and tPA admin has been about getting BP down into a safe range, not worrying about whose BP is too low. But the big result from the first paper was that a diastolic of < 70 mmHg, a systolic less than 155, or an MAP of less than 100 mmHg was associated with higher mortality at 90 days than those with higher BPs (even after adjusting for age, gender, NIHSS score, etc). The worst relative risk (RR) was for a diastolic less than 70; RR = 2.2 in that case, which the authors find is actually worse than the RR of having a diastolic over 105 (RR=1.9… How about that).   

Lactate in the ED, Death on the Floors

I gave a talk last week on the workup of nonsevere sepsis that referenced a bunch of little papers, and a few big ones… We’ll leave the discussion of the landmark 2001 EGDT severe-sepsis talk for another time (sigh). Right now I just wanted to go over an Annals paper (AEM Vol 45, No 5, May ’05) by Shapiro et al from Beth-Israel Deaconess, about lactate in the ED. They were looking at the value of ED serum lactate levels as a predictor of later mortality — echoing studies on ICU lactate and mortality for patients with septic shock, burns, or trauma.

CTA vs. CTA/CTV for Pulmonary Embolism

Annals was mostly about airway this month, and felt a little sparse (Levitan showed that BURP and cricoid pressure worsen the view compared to bimanual laryngoscopy– stop the presses! Also, a letter to the editor advocated for the mnemonic LEMONS over LEMON — the extra S is for O2 saturation, which of course you might otherwise fail to consider as you're prepping to intubate… sheesh).

So, instead, I thought I'd hit up that other noteworthy periodical, the New England Journal of Medicine. This week (June 1, 2006, Vol 354, No. 22) they've got an article (pdf) from the PIOPED II study about the diagnostic value of CT angio alone, vs. CT angio plus CT venography of leg veins.

Validation of San Fransisco Syncope Rule

This month's Annals (May 2006) has an article from Quinn et al. (QuinnAEM-5-06) purporting to validate the San Fransisco Syncope Rule. Also known as "CHESS", the "rule" is positive if any one of the following is true:

• CHF in the past medical history
• Hematocrit < 30
• EKG shows nonsinus rhythm or new changes
• Shortness of Breath
• Systolic < 90 mmHg

In a prospective cohort series, the rule was 98% sensitive (95%CI = 89-100%), 56% specific in predicting "adverse events" within 30 days. Basically, scoring a negative on the San Fransisco rule can make you feel better about sending a patient home. Though, let's be honest, if the test is really 89% sensitive (as the confidence interval allows) than this rule creates an "unnaceptably high" rate of serious outcomes. More below!