Bottom line: Cardiac stress testing adds little to the diagnostic evaluation for patients younger than 40 years having nondiagnostic ECG and negative serial biomarker results. However, routine provocative testing is unlikely to decrease until better clinical risk-stratification tools exist for this very-low-prevalence population.
Citation: Hermann LK, Weingart SD, Duvall WL, Henzlova MJ. The limited utility of routine cardiac stress testing in emergency department chest pain patients younger than 40 years. Ann Emerg Med. 2009;54(1):12-16.
2) Family Witness Behavior Impacts Physician Performance during CPR
Clinical question: Does the presence or behavior of a family witness to cardiopulmonary resuscitation (CPR) alter the critical actions performed by physicians?
Background: Because few patients undergoing in-hospital CPR survive to hospital discharge, many hospitals allow at least one family member of the dying patient to be present during the resuscitation attempt. There is little evidence concerning the bereavement outcomes for the family witness or effect on the resuscitation environment and physician performance.
Study design: Randomized controlled study.
Setting: Human patient simulator-based medical resuscitation environment with standardized actors in an academic medical center.
Synopsis: Sixty second- and third-year emergency medicine residents were randomized in pairs and assigned to one of three groups: no family witness, a non-obstructive witness, or a witness displaying overt grief reactions. Trained actors played the roles of social worker and family member. All groups were joined by the social worker and participated in identical cardiac-arrest-code scenarios ending in asystole. The nurse in each group was scripted to make a potentially harmful medication error. Outcomes studied were physician-performance-based, such as length of the resuscitation attempt, time to critical events, and recognition of a potential drug administration error.
Delay in initiation of defibrillator shocks and decrease in the number of shocks delivered occurred in the overt grief reaction group. Failure to recognize the medication error occurred only once, and it was in the control group. No other significant differences were observed between groups.
Limitations to this study are its small size and possibility that physician behavior in simulated environments might not reflect that of real patient-care situations.
Bottom line: Overt grief reactions from family members witnessing CPR attempts might negatively impact important procedural events and decisions made by physicians, specifically the use of defibrillation, which could negatively affect outcomes of CPR.
Citation: Fernandez R, Compton S, Jones KA, Velilla MA. The presence of a family witness impacts physician performance during simulated medical codes. Crit Care Med. 2009;37(6): 1956-1960.
3) Diltiazem Is a Better Choice in Uncomplicated Atrial Fibrillation than Amiodarone or Digoxin
Clinical question: How does IV diltiazem compare to IV amiodarone or digoxin in achieving ventricular rate control in patients hospitalized for acute uncomplicated atrial fibrillation (AF)?
Background: Current guidelines for acute AF management are based on expert opinion and recommend calcium antagonists, beta-blockers, or digoxin for initial ventricular rate control in hemodynamically stable patients. Recommendations lead to wide clinical variations in the first 24 hours of presentation.
Study design: Randomized, open-label trial.
Setting: Single-center study in Hong Kong.
Synopsis: One hundred fifty patients presenting with acute symptomatic AF of <48 hours duration with a rapid ventricular rate were enrolled. The study endpoints were ventricular rate control within the first 24 hours defined as a sustained heart rate of <90 beats per minute for less than four hours. The time to ventricular rate control in patients assigned to the diltiazem group (three hours) was significantly shorter than that of the digoxin group (six hours) or the amiodarone group (seven hours). The percentage of patients who achieved ventricular rate control in the diltiazem group was 90%, compared with 74% in both the digoxin and amiodarone groups. Length of stay was shorter in diltiazem group (3.9 days) when compared with the digoxin group (4.7 days) and amiodarone group (4.7 days).