Safety of cardioversion in atrial fibrillation lasting less than 48 h without post-procedural anticoagulation in patients at low cardioembolic risk.

Currently, there is no unified consensus on short-term anticoagulation after cardioversion of atrial fibrillation lasting less than 48 h in low-cardioembolic-risk patients. The aim of this study is to evaluate the rate of transient ischemic attacks, stroke and death in this subset of patients after cardioversion without post-procedural anticoagulation. In a prospective observational study, patients with recent-onset AF undergoing cardioversion attempts in the Emergency Department were evaluated over the past 3 years. Inclusion criteria were conversion to sinus rhythm, low thromboembolic risk defined by a CHA2DS2VASc score of 0-1 points for males (0-2 points for females aged over 65 years), and hospital discharge without anticoagulant treatment. Patients with severe valvular heart disease, underlying systemic causes of AF, and those discharged with anticoagulant therapy were excluded. The main outcomes measured were TIA, stroke and death at thirty days' follow-up after discharge. During the study period, 218 successful cardioversions, obtained both electrically and pharmacologically, were performed on 157 patients. One hundred and eleven patients were males (71%), the mean age was 55.2 years (±standard deviation 10.7), 99 patients (63%) reported a CHA2DS2VASc score of 0, and the remaining 58 (37%) had a risk profile of 1 point. Of these, latter 8 were females (5%) older than 65 years (risk score 2 points). At the thirty days outcome, none of the 150 enrolled patients who completed a follow-up visit has reported TIA or stroke, nor died, in the overall 211 successful cardioversions evaluated. In our study, the rate of thromboembolic events after cardioversion of recent-onset AF of less than 48 h duration, in patients with a 0-1 CHA2DS2VASc risk profile (females 0-2), appeared to be extremely low even in absence of post-procedural anticoagulation. These findings seem to confirm data from previous studies, and suggest that routine post-procedural short-term anticoagulation may be considered as an overtreatment in this very low-risk subset of patients.

Safety and feasibility of intravenous rt-PA in the Emergency Department without a neurologist-based stroke unit: an observational study.

Early intravenous thrombolysis has proven to be a safe and effective therapy for selected patients with acute ischemic stroke (AIS). Nowadays, thrombolysis is usually delivered by neurologists in "hub" referral centers. However, only a few among eligible patients actually receive treatment. Barriers to early administration of thrombolysis are represented by delays in presentation to referral centers, in-hospital and transfer delays, as well as changes in symptoms during assessment time. The aim of this study is to evaluate the safety and rate of thrombolysis provided in Emergency Department (ED) of a district hospital without neurological stroke team. Consecutive patients with AIS treated with intravenous thrombolysis were prospectively enrolled in this observational study, conducted between May 2010 and December 2013. The main outcomes evaluated were: mortality, symptomatic intracerebral hemorrhage (ICH), systemic adverse events, and neurological recovery. Secondly, all patients admitted with ischemic stroke were retrospectively screened to assess the reasons for exclusion to treatment and the rate of thrombolysis delivered. During the study period, 43 patients with AIS received intravenous rt-PA treatment. The mortality rate at three months was 9.5 % (4/43; 95 % CI 2.6-22.1) and total ICH at any-time CT scan imaging was 18.6 % (8/43; 8.4-33.4). At seven days or at discharge, 35/43 patients (81.4 %; 66.6-91.6) presented a neurological improvement and 46.5 % (20/43; 31.2-62.3) a complete neurological recovery presenting a normal NIHSS, while 9.5 % of patients remained in steady conditions and other 9.5 % worsened (4/43; 2.6-22.1). Outcomes do not appear to be very different from those reported in SITS-MOST study cohort. Among the overall 732 patients with AIS, 117 (16.0 %; 13.4-18.8) were eligible for age and arrived within the three-hour window of time, and the thrombolysis rate was 5.9 % (43/732; 4.3-7.8). Administration of rt-PA in an ED setting without neurological specialized stroke unit seems to be feasible and safe after adequate training. Thrombolysis rate found seems to be favorably comparable with the national average in specialist stroke units. If such data were confirmed by studies of greater dimension, this may imply the ability to perform thrombolysis even in smaller centers without the neurologist, thus being able to treat a greater number of patients in the times proven effective for thrombolysis.

Proposal for the use in emergency departments of cardiac troponins measured with the latest generation methods in patients with suspected acute coronary syndrome without persistent ST-segment elevation.

UNLABELLED: The purpose of this document is to develop recommendations on the use of the latest generation of cardiac troponins in emergency room settings for the diagnosis of myocardial infarction in patients with suspected acute coronary syndrome (ACS) without persistent ST-segment elevation (NSTE-ACS). The main points which have been addressed reaching a consensus are represented by: Suitability and appropriateness of the terminology. Appropriateness of the request. Confirmation of the diagnosis of myocardial infarction (rule-in). Exclusion of the diagnosis of myocardial infarction (rule-out). WORK METHOD: Each point has been analyzed by taking into account the evidence presented in medical publications. Recommendations were developed using the criteria adopted by the European Society of Cardiology and the American Heart Association/American College of Cardiology (www.escardio.org/guidelines). Each point of the recommendation was submitted for validation to an external audit by a Group of Experts (named above).

Cardioversion in atrial fibrillation. Focus on recent-onset atrial fibrillation.

Atrial fibrillation is the most common sustained arrhythmia encountered in clinical practice. Its prevalence is rising due to an increasing elderly population and the improvement in management of life-threatening diseases such as myocardial infarction and heart failure. Over the past few years effective non-pharmacological treatments, new antiarrhythmics drugs, and anticoagulants have been introduced. Regardless of rate-control or rhythm control strategy, adequate stroke prevention still remains a cornerstone in the treatment of this arrhythmia. This review aims to illustrate the main practical issues in the management of atrial fibrillation, focusing on patients with recent-onset and hemodynamically stable atrial fibrillation.

Toscana virus infections in northern Italy: laboratory and clinical evaluation.

Toscana virus (TOSv) is a neurotropic arthropod-borne virus that causes meningitis in the Mediterranean basin during the summer months. A total of 120 patients suffering from acute aseptic meningitis between July 1 and October 31, 2010 in northern Italy were evaluated. Eighteen of them (15%) were in the acute stage of TOSv disease.

Cardioversion of acute atrial fibrillation in the short observation unit: comparison of a protocol focused on electrical cardioversion with simple antiarrhythmic treatment.

BACKGROUND: Direct current cardioversion (DCC) has been shown to be effective for the management of atrial fibrillation (AF) in the emergency department (ED). Pharmacological cardioversion was compared with a strategy including DCC on patients with uncomplicated, recent-onset (<48 h) AF managed in a short observation unit (SOU). METHODS: A prospective observational study was undertaken over a period of 13 months in two institutions. A DCC-centred protocol was applied to 171 AF cases in a hospital (DCC-cohort) and pharmacological cardioversion to 151 AF cases in another hospital (P-cohort). Patients remaining in AF after 24 h were admitted. The outcomes were rate of discharge in sinus rhythm, length of stay in the ED-SOU, rate of hospitalisation and complications of treatment. Data collected were analysed according to Student t test and χ(2) statistics. RESULTS: Discharge in sinus rhythm was achieved in 159/171 cases in the DCC-cohort and 77/151 cases in the P-cohort (93% vs 51%; number needed to treat (NNT) 2.4; 95% CI 2.0 to 3.1, p<0.001), whereas mean length of stay was 7+7 h in the DCC-cohort and 9+6 h in the P-cohort (p=0.43). Eleven cases from the DCC-cohort and 67 from the P-cohort were admitted (admission rate 6% vs 44%; NNT 2.6; 95% CI 2.2 to 3.5, p<0.001). Three short-term complications occurred in the DCC-cohort and five in the P-cohort (2% vs 3%, p=0.59). Two strokes were registered in the DCC-cohort during 6-month follow-up (p undefined). CONCLUSIONS: Electrical cardioversion of recent-onset AF in the SOU is safe, effective and reduces hospitalisations. Further studies are needed to identify the most cost-effective strategy for the management of AF patients in emergency settings.

Reliability and validity of an Italian four-level emergency triage system.

OBJECTIVES: To measure the reliability and predictive validity of a four-level triage system (I-4L). METHODS: This observational study was conducted in an urban hospital. Five nurses were randomly selected to assign a triage level to 246 paper scenarios, using the I-4L model. The I-4L model is a four-level triage system: urgency category (UC) 1 requires immediate response; UCs 2, 3 and 4 require assessment within 20, 60 and 120 min, respectively. Weighted kappa statistics were used to measure the inter-rater and intrarater reliability of the triage tool and the validity of the model was assessed based on the accuracy in predicting admission and in predicting a reference standard's triage code. RESULTS: The I-4L model's inter-rater reliability was kappa=0.73 (95% CI 0.67 to 0.79), and the intrarater reliability was kappa=0.82 (95% CI 0.67 to 0.96). Its accuracy of triage rating for admission and for prediction of a reference standard's triage code was good: 79% (95% CI 73% to 86%) and 93% (95% CI 89% to 96%), respectively. The percentages of patients admitted per triage level using the I-4L model was: 100% UC 1; 42% UC 2; 6% UC 3; and 2% UC 4. CONCLUSIONS: The I-4L triage model shows a good inter-rater and intrarater reliability for rating triage acuity and for accuracy in patient admission and prediction of a reference standard's triage code.

Reliability and validity of two four-level emergency triage systems.

OBJECTIVE: To measure and compare the reliability and predictive validity of a four-level triage system (I-4L) and the new four-level model triage emergency method (TEM). METHODS: This observational study was conducted in an urban hospital. Ten nurses were randomly selected to assign a triage level to 189 paper scenarios, using either the I-4L model (5 nurses) or the TEM model (5 nurses). We used weighted kappa statistics to measure the interrater and intrarater reliability of each triage tool and assessed the validity of each models based on the accuracy in predicting admission. RESULTS: Interrater reliability was kappa=0.73 [95% CI (confidence interval): 0.59-0.87] and kappa=0.79 (95% CI: 0.65-0.93) with I-4L and TEM, respectively. Intrarater reliability was kappa=0.82 (95% CI: 0.67-0.96) and kappa=0.78 (95% CI: 0.62-0.93), respectively. The accuracy of triage rating for admission prediction was similarly good with I-4L and TEM, namely, 79% (95% CI: 74-85) and 77% (95% CI: 74-85). The proportion of patients admitted per triage level was similar with the two models. CONCLUSION: The interrater and intrarater reliability for rating triage acuity and for accuracy in patient admission prediction was good with both models. Performance with the new model was similar to that of I-4L despite the nurses' short experience. The new TEM model has the advantage of predicting utilization of emergency department resources.

[Chest pain evaluation project]. / Percorso di valutazione del dolore toracico. Valutazione dei requisiti di base per l'implementazione negli ospedali italiani.

The evaluation of acute chest pain remains challenging, despite many insights and innovations over the past two decades. The percentage of patients presenting at the emergency department with acute chest pain who are subsequently admitted to the hospital appears to be increasing. Patients with acute coronary syndromes who are inadvertently discharged from the emergency department have an adverse short-term prognosis. However, the admission of a patient with chest pain who is at low risk for acute coronary syndrome can lead to unnecessary tests and procedures, with their burden of costs and complications. Therefore, with increasing economic pressures on health care, physicians and administrators are interested in improving the efficiency of care for patients with acute chest pain. Since the emergency department organization (i.e. the availability of an intensive observational area) and integration of care and treatment between emergency physicians and cardiologists greatly differ over the national territory, the purpose of the present position paper is two-fold: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the basic critical pathways (describing key steps for care and treatment) that need to be implemented in order to standardize and expedite the evaluation of chest pain patients, making their diagnosis and treatment as uniform as possible across the country.