Miguel Zamorano Serrano. Servicio de Urgencias Hospital Ramón y Cajal.

Miguel Zamorano Serrano.
Servicio de Urgencias
Hospital Ramón y Cajal.
Madrid. 07/11/13
Randomized trials have shown the effectiveness of colchicine in the
treatment of recurrent pericarditis, but evidence has been limited for
its use in treatment of a first episode of acute pericarditis.
In the ICAP trial, in patients with a first episode of acute pericarditis,
adding colchicine to standard antiinflammatory therapy reduced the
risk of recurrence compared with antiinflammatory therapy alone .
We recommend that patients with a first episode of acute
pericarditis be treated with colchicine in addition to standard
antiinflammatory therapy.
Imazio M, Brucato A, Cemin R, et al. A Randomized Trial of Colchicine for Acute
Pericarditis. N Engl J Med 2013.
Pacientes que han tenido un SCA y estan con doble antiagregación a
dosis bajas (AAS y clopidogrel), se recomienda añadir Rivaroxaban
2,5 mg cada 12h, si no hay riesgo de sangrado. (Grade 2B).
Ensayo ATLAS 2 ACS-TIMI 51: En marzo de 2013 fue aprobado por
las agencias europeas de medicina para la prevención secundaria en
pacientes con SCA una vez estabilizados.
La duración del tratamiento seria de un año.
http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medicines/00
0944/smops/Positive/human_smop_000493.jsp&mid=WC0b01ac058001d127.
Time to onset of reperfusion is a critical determinant of outcome
with primary percutaneous coronary intervention (PPCI) in patients
with ST-elevation myocardial infarction (STEMI).
In an observational study of 12,158 STEMI patients diagnosed with a
prehospital electrocardiogram, 10.5 percent bypassed the ED and
were taken directly to the cardiac catheterization laboratory .
ED bypass shortened the time from first medical contact to PPCI and
there was a trend toward a lower adjusted mortality. We support the
use of this approach when feasible.
Bagai A, Jollis JG, Dauerman HL, et al. Emergency department bypass for ST-Segment-elevation
myocardial infarction patients identified with a prehospital electrocardiogram: a report from the
American Heart Association Mission: Lifeline program. Circulation 2013; 128:352.
For the majority of patients with acute upper gastrointestinal
bleeding who do not have significant comorbid illnesses, we
recommend giving blood transfusions to maintain the hemoglobin at
≥7 rather than ≥9 (Grade 1B).
However, patients with active bleeding and hypovolemia may require
blood transfusion despite an apparently normal hemoglobin. For
patients at increased risk of suffering adverse events in the setting
of significant anemia, such as those with unstable coronary artery
disease, we suggest transfusing to maintain the hemoglobin at ≥9
rather than ≥7 (Grade 2C).
Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013;
368:11.
The benefit of intravenous thrombolysis with tissue-type
plasminogen activator (tPA) for acute ischemic stroke decreases
continuously over time from symptom onset, as previously shown in
a pooled analysis of randomized trial data.
The time-dependent benefit of tPA has now been confirmed in a
registry that analyzed data from over 58,000 patients treated with
tPA within 4.5 hours of ischemic stroke symptom onset .
Earlier treatment was associated with increased rates of
independent ambulation and discharge to home, and decreased
rates of death and symptomatic intracranial hemorrhage.
Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activator
and outcome from acute ischemic stroke. JAMA 2013; 309:2480.
The optimal duration of systemic glucocorticoid therapy for an
exacerbation of COPD is not clearly established, but preliminary
evidence suggests that a five-day course is not inferior to the
traditional 10 to 14 days.
The ReDuction in the Use of Corticosteroids in Exacerbated COPD
(REDUCE) trial randomly assigned over 300 patients with acute
exacerbations of COPD, of whom 289 required hospitalization, to
prednisone 40 mg daily for 5 or 14 days [4].
No differences were noted in the time to the next exacerbation, the
likelihood of an exacerbation in the subsequent 180 days, the
recovery of lung function, or treatment-related adverse effects, such
as hyperglycemia and hypertension.
While this study suggests that a five-day course may be comparable
to 14 days for many patients, further study is needed to determine
whether some patients might do better with the longer course
Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid
therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE
randomized clinical trial. JAMA 2013; 309:2223
To prevent spontaneous bleeding in patients with severe
thrombocytopenia from bone marrow suppression, standard practice
is to transfuse platelets prophylactically at a specified threshold
platelet count (usually 10,000/microL).
Two randomized trials in patients with severe thrombocytopenia
have compared this approach with therapeutic transfusion only for
active bleeding .
Compared with patients who were transfused for a threshold
platelet count of ≤10,000/microL, patients who were only
transfused for active bleeding had more frequent episodes of
bleeding and more severe bleeding (including fatal intracranial
hemorrhage). These results support the current practice of
prophylactic platelet transfusion at a threshold platelet count of
10,000/microL in this population
Stanworth SJ, Estcourt LJ, Powter G, et al. A no-prophylaxis platelet-transfusion strategy
for hematologic cancers. N Engl J Med 2013; 368:1771.
Wandt H, Schaefer-Eckart K, Wendelin K, et al. Therapeutic platelet transfusion versus
routine prophylactic transfusion in patients with haematological malignancies: an openlabel, multicentre, randomised study. Lancet 2012; 380:1309.
Ultrasound guidance is useful for the placement of peripheral
intravenous catheters in those with difficult access.
A systematic review identified seven trials, including nearly 300
adults and children with difficult access, which
evaluated ultrasound assistance in the placement of peripheral
intravenous catheters . Successful cannulation was more frequent
with ultrasound guidance compared with no ultrasound guidance
(79 versus 62 percent).
There were no differences in time to successful cannulation, or
number of percutaneous skin punctures.
Egan G, Healy D, O'Neill H, et al. Ultrasound guidance for difficult peripheral venous
access: systematic review and meta-analysis. Emerg Med J 2013; 30:521.
The role of bedside ultrasound to determine which patients undergo
incision and drainage of a skin infection is not well defined.
It may be most helpful when the presence of a skin abscess is not
clinically evident (eg, patients with no drainage or fluctuance). As an
example, in a prospective observational study of nearly 400 children
with skin and soft tissue infections, bedside ultrasound had a much
higher sensitivity and specificity than clinical examination for the
159 children in whom abscesses were not clinically evident
(sensitivity 78 versus 44 percent, specificity 61 versus 42 percent,
respectively)
By contrast, bedside ultrasound did not significantly change the
sensitivity and specificity for the detection of clinically evident
abscesses when compared to physical examination (sensitivity 93
versus 95 percent and specificity 81 versus 84 percent,
respectively).
Marin JR, Dean AJ, Bilker WB, et al. Emergency ultrasound-assisted examination of skin
and soft tissue infections in the pediatric emergency department. Acad Emerg Med
2013; 20:545.
The safety and efficacy of apixaban was studied in two large
randomized trials for the treatment of acute venous
thromboembolism (VTE) and prevention of recurrent VTE .
These studies suggest that apixaban is a safe and effective therapy
for the treatment of acute VTE and prevention of recurrent VTE.
Apixaban is not yet approved for use for this indication, and we
await further data on the safety of apixaban before advocating its
use.
Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous
thromboembolism. N Engl J Med 2013; 369:799.
Agnelli G, Buller HR, Cohen A, et al. Apixaban for extended treatment of venous thromboembolism. N
Engl J Med 2013; 368:699.
The optimal method of switching patients with atrial fibrillation (AF)
from warfarin to a newer oral anticoagulant, such as rivaroxaban, is
not known.
The protocol for the ROCKET AF trial, which compared warfarin to
rivaroxaban, mandated that patients who were previously taking
warfarin could transition to rivaroxaban only when the International
Normalized Ratio (INR) was <3.0 .
Rivaroxaban use in this subgroup of patients resulted in similar
efficacy and safety (primary) outcomes as in the entire cohort of
patients assigned to rivaroxaban. Based on these results, we suggest
starting rivaroxaban (and stopping warfarin) in AF patients
previously treated with warfarin when the INR is <3.0.
Mahaffey KW, Wojdyla D, Hankey GJ, et al. Clinical outcomes with rivaroxaban in patients
transitioned from vitamin K antagonist therapy: a subgroup analysis of a randomized
trial. Ann Intern Med 2013; 158:861.
Oral agents that directly inhibit thrombin or factor Xa are attractive
options for anticoagulation because, unlike heparin and warfarin,
they are used at a fixed dose without monitoring.
However, these drugs lack specific reversal agents to treat
anticoagulant-associated bleeding.
To address this limitation, an antidote for the direct thrombin
inhibitor dabigatran was created using humanized dabigatranspecific antibody fragments In initial studies, the antidote (aDabiFab) bound dabigatran with an affinity 350-fold higher than
thrombin. It neutralized dabigatran activity in vitro and normalized
clotting parameters in a rat model.
Studies to determine the efficacy and tolerability of this agent in
patients are awaited.
Schiele F, van Ryn J, Canada K, et al. A specific antidote for dabigatran: functional and
structural characterization. Blood 2013; 121:3554.
Dabigatran is an oral direct thrombin inhibitor used as
an anticoagulant for atrial fibrillation and venous thromboembolism
treatment and prophylaxis.
In the RE-ALIGN trial, patients who had undergone mechanical heart
valve replacement were randomly assigned to receive dabigatran or
warfarin postoperatively .
The trial was stopped early because of an excess of
thromboembolic and bleeding events in the dabigatran group. We
recommend not using dabigatran in patients with prosthetic heart
valves.
Warfarin or another vitamin K antagonist is the preferred
anticoagulant in such patients.
Eikelboom JW, Connolly SJ, Brueckmann M, et al. Dabigatran versus warfarin in patients
with mechanical heart valves. N Engl J Med 2013; 369:1206.
Dabigatran, a direct thrombin inhibitor, has been studied for the
prevention of recurrent venous thromboembolism.
A randomized trial compared an extended course of dabigatran (6 to
36 months) to warfarin (RE-MEDY) in nearly 3000 patients who had
completed at least three months of anticoagulation (dabigatran or
warfarin) .
When compared with warfarin, dabigatran resulted in a similar rate
of recurrent VTE, without increased risk of bleeding but a
significantly higher rate of acute coronary syndrome.
Dabigatran is not approved for use as a therapy for VTE. We await
further reports on the safety of dabigatran before advocating its use
as an anticoagulant for VTE
Schulman S, Kearon C, Kakkar AK, et al. Extended use of dabigatran, warfarin, or
placebo in venous thromboembolism. N Engl J Med 2013; 368:709.
Miguel Zamorano Serrano.
Servicio de Urgencias.
07/11/13