Friday, October 14, 2011

Yes, Let MONA Fade Away

These authors make a brief argument regarding the inappropriateness of the commonly taught acronym of "MONA" for the initial treatment of acute coronary syndrome.  It is probably the case that well-read Emergency Physicians have since moved on, but it bears repeating.

 - Morphine, which has been associated with worsened outcomes in CRUSADE, but the results are confounded by other factors.  Narcotics are still probably reasonable for nitrate-resistant pain.
 - Oxygen, in which hyperoxia is associated with coronary vasoconstriction, exacerbates reperfusion injury and infarct size.  It is currently recommended that oxygen only be used for patients who are hypoxic.
 - Nitrates, suitable for the relief of anginal symptoms in selected patients.
 - Aspirin, the only element of MONA proven to be strongly beneficial.

And, presumably, future trials will involve the use of newer anti-platelet and other agents in the inital treatment of ACS.

The market is ripe for a replacement acronym!

"Initial treatment of acute coronary syndromes.  Is there a future for MONA acronym after the 2010 guidelines?"

Thursday, October 13, 2011

High-Sensitivity Troponin For Better Or Worse

The premise of this article seems fine - as we all learned in medical school, the LDH CK-MB Troponin is now our most sensitive and specific assay for myocardial injury, but, we were also taught that it takes a certain amount of time for the assay to turn positive.  Thus, the inpatient rule-out with multiple sets of cardiac enzymes.  These investigators looked a new assay, with a lower detection limit, and hope to prove that it has 100% sensitivity with a single measurement, obviating the need for additional enzymatic testing.

There were two phases - a cohort observational portion and a clinical deployment portion.  The observational phase was intended to verify prior data suggesting 99% sensitivity for the assay and, of their 703 patients, 195 had initial hs-cTnT levels of <3ng/L - and none had acute MI in their 6 month follow-up period (97.8 to 100% sensitivity).  In their clinical deployment phase, they collected 915 patients who received two sets of the hs-cTnT assay, and found that only one patient had a subsequent hs-cTnT rise after an initially undetectable hs-cTnT, giving a sensitivity of 99.8% (99.1-100).

So, they say, there is no longer any realistic need to get multiple sets of cardiac enzymes in a patient if the first level is undetectable.  This is probably true, but whether it reduces inpatient stays and follow-up invasive cardiac testing is another matter.  My guess is that widespread availability of this assay would lead to clinicians ordering troponins on patients they wouldn't have previously ordered them on, and - perhaps you know how this story will probably play out - a story in which use of the d-Dimer assay would decrease chest imaging for pulmonary embolism, but didn't.  Too many clinicians are applying it incorrectly and using its weak positive likelihood ratio to light up patients unnecessarily, and I expect this to lead to more patients being kept for testing, not fewer, as the authors propose.

"Rapid Exclusion of Acute Myocardial Infarction in Patients With Undetectable Troponin Using a High-Sensitivity Assay"

Tuesday, October 11, 2011

Popular Dehydration Scales Fare Poorly In 3rd-World Use

I like the author's use of the word "popular" to describe pediatric clinical dehydration scales.  In case you're not part of the "in crowd", today's "popular" dehydration scales include the World Health Organization scale, the Gorelick scale, and the Clinical Dehydration Scale.

This article is a prospective application of each of the three scales by a healthcare provider upon admission to one of three hospitals in Rwanda.  Children were weighed on admission and then on discharge, and the gain in weight was used as the gold standard for comparison to each standardized dehydration scale.

So, bad news:  each of these dehydration scoring scales is too complicated to hold in working memory, and you'd have to have it posted on a wall.

But, good news:  in the words of the authors, "The WHO scale, Gorelick scale, and CDS did not have an area on the ROC curve statistically different from the reference line."

Which means, you get to save your wall space because the dehydration scales gave false negatives or false positives as frequently as they gave true negatives and true positives.  More research is necessary to derive more accurate clinical assessment of children presenting with possible dehydration.

"Comparing the accuracy of the 3 popular clinical dehydration scales in children with diarrhea."

Monday, October 10, 2011

600mg Is Probably Your Best Clopidogrel Loading Dose

Most STEMI is the result of an acute thrombotic event, so, more thrombotic inhibition is better, right?  Italy, Hungary, Serbia and Belgium band together for ARMYDA-6 to test a randomized, prospective 600mg vs. 300mg clopidogrel loading dose prior to PCI in STEMI.

They didn't look at mortality and only followed 30-day outcomes - probably because they didn't have statistical power from only 201 patients to detect a difference - but their surrogate markers of infarct size, successful PCI, LVEF and 30-day "major cardiovascular events" all favored clopidogrel.  Unfortunately, almost every nonsignificant difference between the two clinical groups favored the 600mg group - younger, less diabetes, fewer prior MIs, higher LVEF at baseline, faster loading and cath lab times, less multivessel disease, more TIMI flow >1 pre-PCI.

That being said, it's consistent with the prior ARMYDA-1 and CURRENT-OASIS studies, and even if this isn't a fabulous study, it's another but of evidence to consider.

"Outcome Comparison of 600- and 300-mg Loading Doses of Clopidogrel in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segement Elevation Myocardial Infarction"