THE EMCREG-INTERNATIONAL HYPERTENSION CONSENSUS PANEL: MANAGEMENT OF HYPERTENSIVE EMERGENCIES
MARCH 2008
Through this EMCREG-International Newsletter, Drs. Anna Marie Chang and Judd Hollander discuss the pathophysiology of hypertension, as well as describe historical and physical examination findings crucial for the evaluation of end organ damage. Descriptions of hypertension associated with the following disease processes: Asymptomatic Hypertension, Acute Coronary Syndrome, Acute Heart Failure Syndromes, Neurological Emergencies, Cocaine or Amphetamine Induced Hypertension, and Aortic Dissection are provided with treatment recommendations. Through collaboration with colleagues from a variety of specialties, patients with hypertension can receive optimal therapy when
presenting to any acute care setting. It is our hope you will find this EMCREG-International Newsletter, and the full manuscript of
the Hypertension Consensus Panel which forms the basis for this Newsletter, helpful in the care of your patients with hypertension.
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ACEP 2007 MONOGRAPH: ADVANCING THE STANDARD OF CARE - CARDIOVASCULAR, NEUROVASCULAR AND INFECTIOUS EMERGENCIES
FEBRUARY 2008
EMCREG–International is pleased to present this complimentary 99-page CME monograph covering the proceedings of our 2007 satellite symposium at the ACEP Scientific Assembly in Seattle, Washington, Louisiana. A number of important topics are covered in this monograph including acute coronary syndrome, the diagnosis of transient ischemic attack and stroke, the treatment of ischemic and hemorrhagic stroke, the management of hypertension in acute neurovascular emergencies, the management of hypertensive urgencies and emergencies, markers for severe bacterial infections, the treatment of sepsis, risk stratification of possible acute coronary syndrome, the optimal management of NSTEMI and STEMI, treatment of acute heart failure syndrome, and the diagnosis and treatment of deep venous thrombosis and pulmonary embolism.
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NEW! MANAGEMENT OF HYPERTENSION AND HYPERTENSIVE EMERGENCIES IN THE EMERGENCY DEPARTMENT: THE EMCREG-INTERNATIONAL CONSENSUS PANEL RECOMMENDATION
MARCH 2008
This supplement [Ann Emerg Med 2008;51(3 Suppl 1):S1-S38] represents the first supplement to Annals of Emergency Medicine in nearly 16 years! These consensus documents on the evaluation and management of hypertension and hypertensive emergencies in the ED was systematically developed between December 2006 and April 2007 in an evidence-based and consensus-based process and culminated in the March 2008 supplement of Annals. This consensus document on the evaluation and management of hypertension and hypertensive emergencies in the ED was systematically developed between December 2006 and April 2007 in an evidence-based and consensus-based process. The panel members were selected from a multidisciplinary group of specialists, which included physicians from emergency medicine, neurology, neurological surgery, internal medicine, hospital medicine, nephrology, cardiology, pediatrics, anesthesiology, vascular surgery, and gynecology and obstetrics. Each specific hypertension section or topic was assigned at least 2 experts, one of whom was usually an emergency physician.
NEW! DRUG TREATMENT FOR HYPERTENSIVE EMERGENCIES
JANUARY 2008
Hypertensive emergencies represent one of the most common presentations to the emergency department, as many as 3% of visits in one study. For emergency physicians, early diagnosis and appropriate treatment are essential for minimizing injury due to elevated blood pressure. In some cases, this management of hypertension can be life saving. This Newsletter focuses on the drug treatment of hypertensive emergencies, primarily parenteral therapy. The drugs of choice for the treatment of each diagnostic category are discussed with
the evidence supporting these recommendations.
SICK OR NOT SICK? : EVOLVING BIOMARKERS FOR SEVERE BACTERIAL INFECTION
NOVEMBER 2007
In the United States, sepsis accounts for over 751,000 cases, 215,000
deaths, and 16.7 billion dollars in health care costs annually. Severe sepsis kills more individuals than breast, colon, rectal, pancreatic, and
prostate cancer combined.1-3 With the difficulties associated with access to primary care and more aggressive emphasis on rapid hospital discharge
and outpatient surgeries, sepsis ranks as one of the highest prevalence, highest mortality, and most expensive conditions that an emergency physician
will encounter.
RISK STRATIFICATION FOR PATIENTS WITH NON-ST-SEGMENT ELEVATION ACUTE CORONARY SYNDROMES IN THE EMERGENCY DEPARTMENT
OCTOBER 2007
Unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) accounted for 1,295,000 hospital admissions in the US in 2001, almost 60% of those patients were 65 years of age or older, and 41% were women. The National Center for Health Statistics recently reported 5,637,000 US emergency department (ED) chest-pain syndrome visits, accounting for approximately 5% of total visits. Accurate diagnosis and risk stratification of the UA/NSTEMI patient is essential to identify patients at risk and to initiate appropriate treatment.
USE OF DIRECT THROMBIN INHIBITORS FOR TREATING NON-ST-SEGMENT ELEVATION ACUTE CORONARY SYNDROMES IN SPECIAL PATIENT GROUPS: WOMEN, DIABETICS, THE ELDERLY, AND CHRONIC RENAL INSUFFICIENCY
SEPTEMBER 2007
This complimentary newsletter provides a targeted review of the results of the ACUITY trial with particular emphasis on the high risk populations - women, elderly, diabetics, and patients with chronic renal insufficiency. In addition, he describes the findings of ACUITY in relation to therapy "switch", when patients were initially treated with heparins prior to randomization. Emergency physicians are increasingly becoming exposed to a greater variety of therapies for patients with acute coronary syndrome. It is our hope to provide you, the practicing clinician, with the educational tools to continue to give outstanding care to your patients.
CRUSADE: CONTEMPORARY EVALUATION AND MANAGEMENT OF 200,000 HIGH-RISK NSTE-ACS PATIENTS
AUGUST 2007
After six years and the enrollment of over 200,000 patients, the CRUSADE national quality improvement and educational initiative ended on January 31, 2007. This date brought to a close an invaluable and unprecedented compilation of data on the management of patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), as well as important data on a smaller but very contemporary cohort of patients with acute ST-segment elevation myocardial infarction (STEMI).
DIAGNOSIS AND RISK STRATIFICATION OF ACUTE HEART FAILURE SYNDROMES
AUGUST 2007
The evaluation and management of emergency department patients with potential acute heart failure syndrome have remained a significant challenge for decades. Dramatically, unlike advances for the assessment and treatment of patients with acute coronary syndrome, the emergency physician’s diagnostic tools for heart failure have remained limited. The complexity and morbidity of this syndrome alone has led to risk aversion and extremely high admission rates. These difficulties, as well as the increasing prevalence and incidence of heart failure due to improved treatment of ACS and our aging population, has placed an enormous burden on healthcare resources worldwide.
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PULMONARY EMBOLISM AND DEEP VENOUS THROMBOSIS: EVALUATION AND TREATMENT IN THE EMERGENCY DEPARTMENT
JUNE 2007
Venous thromboembolism (VTE) is a clinical entity which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE is a common medical condition affecting up to 117 patients per 100,000 population annually.1 The diagnosis of VTE is often difficult and frequently missed. Mortality in untreated PE is approximately 30%, but with adequate anticoagulant treatment, this can be reduced to 2–8%. The purpose of this Newsletter is to focus on the diagnosis and treatment of VTE, including PE and DVT in the emergency department (ED). In this EMCREG-International Newsletter, Dr. Charles Cairns, Associate Professor of Surgery and Medicine and Associate Chief of Emergency Medicine at the Duke University School of Medicine discusses the important disease process venous thromboembolism (VTE) which includes deep venous thrombosis and pulmonary embolism from the perspective of emergency medicine.
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DIRECT THROMBIN INHIBITORS IN NON-ST-SEGMENT ELEVATION ACUTE CORONARY SYNDROMES
MARCH 2007
For patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS) presenting to the emergency department, appropriate anti-thrombotic and anti-platelet therapy is critical to optimize outcome. Unfractionated heparin is often given as an anti-thrombin in this setting, however, if suffers from a number of pharmacologic limitations including non-specific binding, the requirement for frequent monitoring of its anti-coagulant effect, and the formation of antibodies to the heparin/platelet factor 4/platelet complex which can cause heparin-induced thrombocytopenia (HIT) or heparin-induced thrombocytopenia thrombosis syndrome (HITTS). Low molecular weight heparins, also an indirect thrombin inhibitor, can be used without monitoring their anti-thrombin effects. Ease of use and effectiveness makes them a popular choice in the emergency setting.
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ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI):
DECREASING THE TIME TO TREATMENT IN THE EMERGENCY DEPARTMENT
JANUARY 2007
Patients presenting to the Emergency Department (ED) with
ST-segment elevation acute myocardial infarction (STEMI) require rapid diagnosis and treatment to optimize their
outcome. Early diagnosis is accomplished by acquiring a 12-lead electrocardiogram within 10 minutes after ED presentation
to identify STEMI and then begin treatment. Most irreversible myocardial damage occurs within the first 3 hours after
symptom onset so delivery of fibrinolytic therapy or mechanical opening of the coronary artery using percutaneous coronary
intervention (PCI) must be initiated early after presentation to the hospital to achieve greatest benefit.
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FULL ACEP 2006 MONOGRAPH: ADVANCING THE STANDARD OF CARE - CARDIOVASCULAR AND NEUROVASCULAR EMERGENCIES DECEMBER 2006
EMCREG–International is pleased to present this complimentary 84-page CME monograph covering the proceedings of our satellite symposium at the ACEP Scientific Assembly in New Orleans, Louisiana. A number of important topics are covered in this monograph including management of non-ST-segment elevation and ST-segment elevation acute coronary syndrome (ACS), the CRUSADE Quality Improvement Initiative, decreasing time to treatment for ST-segment elevation myocardial infarction, direct thrombin inhibitors in ACS, acute decompensated heart failure care, the use of lactate as a marker for trauma and sepsis, point-of-care testing for cardiac biomarkers, the management of hypertension in acute neurovascular emergencies and advances in acute stroke care.
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COMPUTERIZED TOMOGRAPHIC CORONARY ANGIOGRAPHY FOR THE EVALUATION OF ED PATIENTS WITH POTENTIAL ACUTE CORONARY SYNDROMES
DECEMBER 2006
The diagnosis of acute coronary syndrome (ACS) represents one of the most difficult tasks facing clinicians in the acute care environment. In this EMCREG-International Newsletter, Drs. Judd Hollander and Howard Litt describe an important new modality for visualizing the coronary artery anatomy in patients with possible ACS – using 64-slice multidetector computed tomography coronary angiography.
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HYPERTENSION MANAGEMENT IN ACUTE NEUROVASCULAR EMERGENCIES
NOVEMBER 2006
For patients with acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, appropriate treatment is based on understanding the complex pathophysiology of these disease processes as well as the characteristics of the drugs used to treat hypertension in these individuals. In this clinical update newsletter, Dr. Arthur Pancioli expands the knowledge base of emergency physicians and all clinicians treating these critically-ill patients will improve outcome.
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LACTATE – A MARKER FOR SEPSIS AND TRAUMA
SEPTEMBER 2006
While lactate testing has been in medical arena
for over a century, its utility in the emergency department for the evaluation of these potentially critically ill patients is only now being recognized. In this newsletter Andra L. Blomkalns, MD aims to review the present literature on lactate testing in the clinical environment as it pertains to its use for emergency department patients.
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POINT-OF-CARE TESTING FOR CARDIAC BIOMARKERS IN THE ED:
A BLUEPRINT FOR IMPLEMENTATION
JULY 2006
The development of a POC testing program will require collaboration between emergency physicians and cardiologists, laboratorians, and hospital administrators. As the individual POC tests often cost more than the batch run central laboratory assays, determining the cost effectiveness of POC testing requires an understanding of how faster results can decrease time to disposition from the emergency department and speed the delivery of guideline-based therapies to patients with ACS.
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ACEP 2005 MONOGRAPH : CARDIOVASCULAR AND NEUROVASCULAR EMERGENCIES AND POINT-OF-CARE TESTING
JANUARY 2005
The Emergency Medicine Cardiac Research and Education Group (EMCREG)-International is pleased to present this monograph representing the proceedings of our satellite symposium at the ACEP Scientific Assembly in Washington, DC, in late September of 2005. In this monograph, you will find a variety of important topics covered including the CRUSADE Quality Improvement Initiative, clopidogrel’s use in ST-segment elevation myocardial infarction, low molecular weight heparins in acute coronary syndromes, dyslipidemia, diagnosis and treatment on acute decompensated heart failure, evaluation of pulmonary embolism, cardiac biomarkers in point-of-care testing, the Stroke Center certification concept, evaluation of transient ischemic attacks, and the role of serum biomarkers in the diagnosis of stroke.
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USE OF NT-PROBNP IN THE EMERGENCY DEPARTMENT EVALUATION OF SHORTNESS OF BREATH: IMPLICATIONS FOR CLINICAL PRACTICE
December 2005
In this EMCREG-International newsletter, Sean P. Collins, MD, Assistant Professor of Emergency Medicine at University of Cincinnati, OH discusses incidence of heart failure has been rising over the last decade as more patients survive significant myocardial infarction, as well as other diseases which compromise the heart. All clinicians who care for these patients must be aware of the many diagnostic and therapeutic approaches to these often critically-ill patients. NT-proBNP provides an important diagnostic and prognostic test for these heart failure patients.
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THE ROLE OF NESIRITIDE IN THE MANAGEMENT OF ADHF: REVIEW OF MORTALITY DATA AND RECOMMENDATIONS FOR CLINICAL USE
OCTOBER 2005
In this EMCREG-International newsletter, J. Douglas Kirk, MD, Associate Professor of Emergency Medicine at UC Davis Sacramento, CA discusses the current data regarding nesiritide which provides perspective on this controversial issue for the practicing emergency physician.
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INTERPRETATION OF CARDIAC TROPONINS IN PATIENTS WITH CHRONIC KIDNEY DISEASE AND SUSPECTED ACUTE CORONARY SYNDROME IN THE EMERGENCY SETTING
AUGUST 2005
This summary provides a detailed discussion of the interpretation of elevated values in patients with chronic kidney disease and acute
coronary syndrome for this EMCREG-International newsletter. It is our hope that the readers of this newsletter will find their evaluation of patients with
chronic kidney disease and acute coronary syndrome more effective, resulting in improved patient care.
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THE FUTURE OF CARDIAC BIOMARKERS
JUNE 2005
In this EMCREG-International newsletter, Judd E. Hollander, MD, from the Hospital of the University of
Pennsylvania, discusses the development and current emergency department use of cardiac necrosis biomarkers (CK-MB, troponin, myoglobin), biomarkers
of inflammation (C-reactive protein), and newer cardiac biomarkers of myocardial ischemia (brain natriuretic peptide). It is our hope to provide emergency physicians with a better understanding of the cardiac
biomarkers used in emergency practice for diagnosis of ACS.
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EMERGENCY DIAGNOSIS AND TREATMENT OF ACUTE DECOMPENSATED HEART FAILURE (ADHF)
JUNE 2005
Each year, nearly one million patients in the United States are hospitalized with acute decompensated heart failure (ADHF). In the past, there have been limited practice guidelines for the emergency management of ADHF within the spectrum of heart failure. Data from the ADHERE (the acute decompensated heart failure national registry),indicates that these patients are repeatedly hospitalized, and otherwise have a very high rate of morbidity and mortality. The management and care of this patient group remains suboptimal.
This CME activity will review the latest diagnostic and therapeutic modalities for ADHF and suggest methods to improve the care for these patients at your institution. Insights and lessons from ADHERE will also be reviewed and discussed.
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CRUSADE - A ROADMAP FOR CHANGE: 100,000 PATIENTS MAKE A DIFFERENCE. INTERIM ANALYSIS OF THE 100,000 PATIENTS ENROLLMENT MILESTONE
MARCH 2005
It is with great pleasure that we present this EMCREG International newsletter report describing the first 100,000
patients enrolled into the CRUSADE quality improvement initiative, particularly from the perspective of the emergency physician. This unique clinical program, coordinated by
the Duke Clinical Research Institute (DCRI) in Durham, North Carolina represents a remarkable collaboration between Emergency Medicine and Cardiology in
over 400 acute care hospitals across the United States.
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THE EVOLVING ROLE OF BNP IN THE DIAGNOSIS AND TREATMENT OF CHF: A SUMMARY OF THE BNP CONSENSUS PANEL REPORT -
A SUMMARY FOR EMERGENCY PHYSICIANS
JANUARY 2005
Dr. Frank Peacock, of the Cleveland Clinic, provides detailed summaries of the diagnostic and therapeutic approaches for HF using BNP based on the BNP Consensus Panel
recommendations published in September, 2004 in Congestive Heart Failure. We hope this EMCREG-International newsletter provides useful information which helps you provide care to patients with HF.
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2004 ACC/AHA GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH STEMI:
CLASS 1 RECOMMENDATIONS PERTINENT TO THE EMERGENCY DEPARTMENT
DECEMBER 2004
In August, 2004 the American College of Cardiology/American Heart Association 2004 ST-segment Elevation
Myocardial Infarction (STEMI) guidelines were published. This treatise presents a comprehensive approach to the diagnosis and treatment of STEMI extending from the
first pre-hospital medical contact of the patient with an ambulance, through emergency department care, to the appropriate approach to these patients on hospital discharge
and beyond. The Emergency Medicine Cardiac Research and Education Group (EMCREG)-International has provided, through this concise summary of the STEMI guidelines, a practical
approach for emergency physicians for this disease process.
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CARDIOGENIC SHOCK COMPLICATING ACUTE MYOCARDIAL INFARCTION: A SILVER LINING ON THE HORIZON?
NOVEMBER 2004
We are pleased to present this cutting edge clinical update report on cardiogenic shock (CS). Acute coronary syndromes
and its complications are key components of emergency medicine practice. Specifically, CS is prevalent and occurs in roughly 10% of all cases of acute myocardial
infarction (AMI). Despite numerous therapeutic advances in the treatment of cardiovascular disease, CS is still the leading cause of mortality among patients with AMI. This newsletter by Drs. Jeger, Anand and Hochman
summarizes the classic CS paradigm and observations from the SHOCK trial challenging that paradigm.
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2004 ACEP Symposium: Advancinge the Standard of Care
OCTOBER 2004
EMCREG-International is pleased to present this educational monograph summarizing our 2004 ACEP Satellite Symposium on cardiovascular and neurovascular emergency care held in San Francisco. Topics presented included: Point-of-Care Testing for ACS in the ED; STEMI Time-to-Treatment; Chest Pain Center; Heart Sound Recording; Anti-Platelet and Anti-Thrombotics in ACS; BNP Consensus Panel; Stroke, and Intracerebral Hemorrhage. It is our hope that this material will provide emergency physicians with information necessary to help care for these seriously ill patients.
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CARDIOVASCULAR and NEUROVASCULAR EMERGENCIES: Implications for Clinical Practice (ACEP 2003)
By popular demand, each of our ACEP Symposia are followed by a CME monograph capturing the presentations given at the event.
This CME Monograph captures the material presented at
the EMCREG Symposium held during the 2003 ACEP meeting
in Boston, MA. These monographs are a popular enduring material piece for your library.
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THIRD AND FOURTH HEART SOUNDS – LOST ART TO MODERN ADVANCE
Even the most proficient of emergency care providers have difficulty discerning the low frequency rumblings of an S3 or S4 from the background noise of monitors in a hectic emergency setting. Nearly half a century has passed since phonocardiography originally was developed to assist in cardiac auscultation. Modern technology is now making it possible to once again use
the analysis and reporting of S3 and S4 heart sounds to facilitate the diagnosis of heart failure and acute coronary syndrome (ACS).
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MODERN ADVANCES IN EMERGENCY CARDIAC CARE: EVOLUTION OF DIAGNOSTIC AND TREATMENT OPTIONS
(ACEP 2002)
Patients presenting to the Emergency Department (ED) with chest pain remain a major clinical challenge. In the United States alone there are over eight million annual visits for this problem resulting in over four million admissions for possible acute coronary syndromes (ACS). The diagnosis and treatment of congestive heart failure (CHF) is also critically important to emergency physicians as 550,000 new cases present annually. Therefore, it is critical for the emergency physician community remain on the forefront of state of the art diagnostic and treatment options involving the
newest regimens for ACS and CHF.
EMCREG-International is pleased to present this educational CME monograph summarizing our 2002 EMCREG Symposium on cardiovascular emergency care held in Seattle, Washington. It is our hope that this material will provide emergency physicians with information necessary to help care for these seriously ill patients.
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ACC/AHA 2002 Guidelines for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: A SUMMARY FOR EMERGENCY PHYSICIANS
The CME enduring material was delivered to the membership of the American College of Emergency Physicians. The information contained in these guidelines has important implications for emergency medicine physicians on the forefront of managing this high-morbidity and complicated patient population. For the purposes of this summary, we will concentrate on initial
evaluation and management of patients with appropriate attention to the other sections as indicated for the emergency physician. These guidelines provide the opportunity to practice medicine in an evidence-based fashion and hopefully provide the most beneficial care for our patients.
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