Existing PA program curricula are insufficient for developing critical skills related to ultrasonography.
ObjectiveFew studies have prospectively evaluated the diagnostic accuracy and temporal impact of ultrasound in the emergency department (ED) in a randomized manner. In this study, we aimed to perform a randomized, standard therapy controlled evaluation of the diagnostic accuracy and temporal impact of a standardized ultrasound strategy, versus standard care, in patients presenting to the ED with acute dyspnea.MethodsThe patients underwent a standardized ultrasound examination that was blinded to the team caring for the patient. Ultrasound results remained blinded in patients randomized to the treating team but were unblinded in the interventional cohort. Scans were performed by trained emergency physicians. The gold standard diagnosis (GSDx) was determined by two physicians blinded to the ultrasound results. The same two physicians reviewed all data >30 days after the index visit.ResultsFifty-nine randomized patients were enrolled. The mean±standard deviation age was 54.4±11 years, and 37 (62%) were male. The most common GSDx was acute heart failure with reduced ejection fraction in 13 (28.3%) patients and airway diseases such as acute exacerbation of asthma or chronic obstructive pulmonary disease in 10 (21.7%). ED diagnostic accuracy, as compared to the GSDx, was 76% in the ultrasound cohort and 79% in the standard care cohort (P=0.796). Compared with the standard care cohort, the final diagnosis was obtained much faster in the ultrasound cohort (mean±standard deviation: 12±3.2 minutes vs. 270 minutes, P<0.001).ConclusionA standardized ultrasound approach is equally accurate, but enables faster ED diagnosis of acute dyspnea than standard care.
Acute heart failure (AHF) presents symptoms primarily the result of pulmonary congestion due to elevated left ventricular (LV) filling pressures with or without reduced ejection fraction (EF). Common precipitating pathology includes coronary artery disease (CAD), hypertension and valvular heart diseases, in addition to other noncardiac conditions, such as diabetes, anaemia and kidney dysfunction. 1,2Additionally, AHF poses major medical and socioeconomic burdens.It represents the most common discharge diagnosis in patients over 65 years of age in the US, and an AHF patient that requires hospitalisation has a 90-day mortality approaching 10 %. 3,4 The cornerstone of AHF treatment is diuretics and vasodilators, such as nitrates. Due to a lack of randomised controlled trials, the use of nitrates for management of AHF is not universally adopted.While organic nitrates are among the oldest treatments for chronic stable angina, they are underutilised in AHF. Organic nitrates are available as sublingual tablets, capsules, sprays, patches, ointments or intravenous (IV) solutions, all of which are potent vasodilators.Because of the challenges in AHF research, a data imbalance between acute and chronic HF treatment exists as more studies have been performed in the latter. Thus, the current level of evidence for the use of nitrates in AHF is only rated as 1C, i.e., 'expert opinion'. 5,6 The purpose of this article is to review the clinical efficacy and safety data of nitrates in AHF. Applied to the patient with congestive HF, vasodilatation induces a substantial reduction in biventricular filling pressure. Moreover, it reduces systemic and pulmonary vascular resistance and systemic arterial blood pressure (BP), 11 all of which lead to modest increases in cardiac stroke volume and cardiac output. How Nitrate Works Mechanism of Action 12Overall, the two most commonly used IV NO sources used clinically in the setting of AHF is the organic nitrate donor nitroglycerin, and the inorganic nitrate source sodium nitroprusside (SNP). Nitroglycerin potently dilates large arteries (including coronary arteries) but has less effect on smaller arterioles, while SNP is a predominant arteriolar dilator. That makes SNP is effective in recompensating patients with AHF. 13 Other important clinical differences between organic and inorganic nitrates are summarised in Table 1. AbstractThe purpose of this article is to review the clinical efficacy and safety of nitrates in acute heart failure (AHF) by examining various trials on nitrates in AHF. Management of AHF can be challenging due to the lack of objective clinical evidence guiding optimal management.There have been many articles suggesting that, despite a benefit, nitrates are underused in clinical practice. Nitrates, when appropriately dosed, have a favourable effect on symptoms, blood pressure, intubation rates, mortality and other parameters.
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