Theme: 
Cardiology.

Participants: 

Dr Aaisha Ferkh (cardiology fellow), Dr Samia Kazi (cardiology fellow), Dr Khanh Nguyen, Dr Pramod Chandru, Kit Rowe, Shreyas Iyer, Caroline Tyers and Samoda Wilegoda Mudalige.

Discussion 1:
Lemkes, J., Janssens, G., van der Hoeven, N., Jewbali, L., Dubois, E., & Meuwissen, M. et al. (2019). Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. New England Journal Of Medicine, 380(15), 1397-1407. https://doi.org/10.1056/nejmoa1816897.  

Take-Home Points:

• This study showed that in patients successfully resuscitated from out-of-hospital cardiac arrest, who did not have STEMI, immediate coronary angiography and revascularisation did not improve survival at 90 days.
• It may be reasonable to consider early coronary angiography in certain patients after discussion with the interventional cardiologist (e.g. if there is a good history of ischemic symptoms prior to the arrest or if the patient has a significant cardiac background).
• It is also important to focus on other aspects of post-resuscitation care e.g. targeted temperature management, vital organ support, and treating the underlying aetiology of the cardiac arrest.

Discussion 2:

Aslanger, E., Yıldırımtürk, Ö., Şimşek, B., Sungur, A., Türer Cabbar, A., & Bozbeyoğlu, E. et al. (2020). A new electrocardiographic pattern indicating inferior myocardial infarction. Journal Of Electrocardiology, 61, 41-46. https://doi.org/10.1016/j.jelectrocard.2020.04.008.

Take-Home Points:

• ECG criteria for this pattern (or "Aslanger’s pattern"): ST-segment elevation isolated to lead III, concomitant ST depression in any of V4 to V6 (with a positive/terminally positive T-wave), and ST-segment in V1 > V2.
• This pattern may indicate inferior MI in patients “with concomitant critical lesion/s in coronary arteries other than the infarct-related artery”.
• This study shows that patients with this particular ECG pattern have a higher risk of short- and long-term mortality than other NSTEMI patients; however, more research is required to corroborate these findings. 
• If the patient has ongoing chest pain (without any other obvious cause), it is important to do serial ECGs and escalate concerns to the cardiology team (regardless of what their ECG might show). 

ECG example (from Life In The Fast Lane):
https://litfl.com/wp-content/uploads/2020/12/Aslanger-pattern-of-ECG-chages-in-inferior-myocardial-infarction-2020.png.

Discussion 3:

Schüpke, S., Neumann, F., Menichelli, M., Mayer, K., Bernlochner, I., & Wöhrle, J. et al. (2019). Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. New England Journal Of Medicine, 381(16), 1524-1534. https://doi.org/10.1056/nejmoa1908973. 

Take-Home Points:

• This study demonstrated that, in patients with ACS (with or without ST-segment elevation), the incidence of death, MI, and stroke was significantly lower among patients who were treated with Prasugrel than among patients who were treated with Ticagrelor. 
• The incidence of major bleeding was similar between the two treatment groups.
• Prasugrel is currently unavailable in the Australian market and in this context, the preferred agent is Ticagrelor (unless it is contraindicated). However, prior to choosing an agent, it is worth discussing with the cardiology team due to variations in individual practice, local protocols, and time of administration. 
• When choosing DAPT, always consider the drug's contraindications and risk of potential complications (e.g. bleeding). If a patient has a higher risk of bleeding and is above the age of 70 years, it might be safer to use Clopidogrel. The main contraindications for use of Ticagrelor are increased risk of bleeding and higher degrees of conduction block. With Prasugrel, watch out for history of stroke as that increases the risk of intracranial bleeding. 

Credits:
The discussions were mediated by ED consultants,  Dr Khanh Nguyen and Dr Pramod Chandru.

This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney, Deepa Dasgupta, Cynthia De Macedo Franco, and Paul Scott.

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See you next time,

Caroline, Kit, Pramod, Samoda, and Shreyas.