2020 ACLS Guidelines on Medications for Management of Specific Arrhythmias

ACLS 2020 arrhythmias

The 2020 ACLS guidelines provide recommendations on the medication-specific management for arrhythmias including wide-complex tachycardia, regular narrow-complex tachycardia, atrial fibrillation/flutter, and bradycardia [1]. There are also our 2020 ACLS guideline summaries on vasopressor and non-vasopressor medications used during cardiac arrest and toxicology-related conditions.

Wide-complex tachycardia (WCT)

Wide-complex tachycardiaMedication(s)Evidence
Hemodynamically stableAdenosineCOR 2b, LOE B-NR
Amiodarone, procainamide, or sotalolCOR 2b, LOE B-R
NOTE: Verapamil is harmfulCOR 3, LOE B-NR
Polymorphic VT with long QT (torsades de points)MagnesiumCOR 2b, LOE C-LD
Polymorphic VT without long QTLidocaine or amiodaroneCOR 2b, LOE C-LD

Regular narrow-complex tachycardia

  1. Vagal maneuvers (COR 1, LOE B-R)
  2. Adenosine (COR 1, LOE B-R)
  3. Diltiazem or verapamil (COR 2a, LOE B-R)
  4. Beta-blockers (COR 2a, LOE C-LD)

Atrial fibrillation/flutter with rapid ventricular rate

  1. Beta-blocker or diltiazem or verapamil (COR 1, LOE B-NR)
  2. Amiodarone (COR 2a, LOE B-NR)


Bradycardia

  1. Treat reversible causes (COE 1, LOE C-EO)
  2. Atropine if hemodynamic compromise (COR 2a, LOE B-NR)
  3. Epinephrine or transcutaneous pacing if unresponsive to atropine (COR 2b, LOE C-LD)

Reference

Panchal AR, Bartos JA, Cabañas JG, et al; Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. Epub 2020 Oct 21. PMID: 33081529.

ACEP E-QUAL: ACEP Non-STEMI Clinical Policy

Clinical Policy

In 2018, the American College of Physicians (ACEP) released a Clinical Policy with management recommendations for patients presenting to the emergency department (ED) with concern for non-ST-elevation myocardial infarction (NSTEMI). Dr. Jason Woods hosted an episode of the ACEP E-QUAL Network podcast highlighting key aspects of the new policy. Dr. Woods was joined by lead writer Dr. Christian Tomaszewski from the University of California San Diego, and Dr. Michael Ross, Director of the Chest Pain Center at Emory University. Below are show notes reviewing the recommendations and the process involved in creating the clinical policy.

 

 

How is a clinical policy different than a practice guideline?

The National Guideline Clearinghouse (NGC), a public resource initiative of the Agency for Healthcare Research and Quality (AHRQ), provides rules and frameworks for evidence-based clinical practice guidelines. ACEP refers to clinical practice guidelines in Emergency Medicine (EM) as policies to denote the more prescriptive design process.

What was the process of drafting the policy?

Development of the 2018 ACEP NSTEMI Clinical Policy was a 2-year “labor of love.” Writers, methodologies, and committee members were required to be free from both financial and intellectual conflict of interest.

The clinical policy is a result of a systematic review and critical analysis of available medical literature. Clinical studies were graded on robustness, design, and class of evidence according to the ACEP policy development process which includes internal and external review.

Recommendations were categorized as reflecting high clinical certainty (Level A), moderate clinical certainty (Level B), or mixed clinical certainty (Level C) due to the heterogeneity of results, unclear effect magnitude, bias, among other factors.

What questions did the policy address?

Four critical questions were decided by consensus methods to address the evaluation and management of adult patients presenting to the ED with concern for NSTEMI.

1) If ST-elevation myocardial infarction is excluded, can a combination of bedside and laboratory evaluation in the ED identify patients at low risk for major adverse cardiac events (MACE)?
Level B recommendation: History, ECG, Age, Risk Factors, Troponin (HEART) score < 3 can be used as a clinical prediction tool for a 30-day MACE miss rate between 0-2%.
Level C recommendation: Thrombolysis in Myocardial Infarction (TIMI) score can be used to predict risk of 30-day MACE.

2) Can repeat Troponin testing in the ED be used to identify patients at low risk for MACE?
Level C recommendations:

    • Conventional troponin testing at hour 0 and 3 in low risk (HEART score < 3) patients can predict and acceptable low risk for 30-day MACE.
    • A single high-sensitivity troponin less than the detectable limit on arrival to the ED or negative serial high-sensitivity troponin at hour 0 and 2 is predictive of a low rate of MACE.
    • Patients deemed to be low risk with a non-ischemic ECG and negative high-sensitivity troponin at 0 and 2 hours can be considered low risk for 30-day MACE, allowing for accelerated discharge from the ED.

3) In patients who have been ruled out for acute coronary syndromes (ACS), does advanced cardiac provocative testing prior to discharge from the ED reduce MACE?
Level B recommendation:  Do not routinely use advanced cardiac testing in low-risk patients who have been ruled out for ACS to further reduce 30-day MACE.
Level C recommendation: Arrange follow-up in 1-2 weeks for low-risk patients in whom ACS has been ruled out. If unable to arrange follow-up, consider observation and advanced testing prior to discharge.

4) Should patients with NSTEMI receive antiplatelet therapy in addition to aspirin in the ED?
Level C recommendation: P2Y12 inhibitors and glycoprotein IIb/IIIa inhibitors can be given in the ED or delayed until cardiac catheterization.

What questions remain?

  1. The clinical policy does not address the “delta factor” involved in assessing changes to the cardiac marker levels that may be seen with repeat testing at set time points.
  2. Duration of pain was not discretely addressed, and differences in real-world practice can exist depending on whether the time of onset or time of presentation is considered for defining repeat testing and observation length.
  3. Shared decision-making was not factored into the selection of management steps.

Important points for consideration:

The 2018 ACEP Clinical Policy for NSTEMI was written for the evaluation of patients with suspicion for ACS who presented with chest pain. It does not apply to those presentations of ACS that are considered atypical in nature.

Click here to read a more in-depth summary of the ACEP Clinical Policy on ALiEM. 

Interested in more of the ACEP-EQUAL Podcast?

Listen to more ACEP E-QUAL podcasts episodes on the ALiEM Soundcloud account.

By |2020-12-09T11:57:39-08:00Dec 7, 2020|Academic, ACEP E-QUAL, Cardiovascular|

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LVAD Part III: Complications

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By |2020-03-30T14:13:04-07:00Mar 30, 2020|Cardiovascular, Emergency Medicine|

LVAD Part II: Diagnostic Evaluation

lvadLeft ventricular assist devices (LVADs) have moved from being a bridge to a heart transplant to destination therapy for patients with severe heart failure. Although their use in the general public has increased, they still provide a challenge to the emergency medicine (EM) physician This series aims to cover the basics of how the EM physician approaches the care of these patients. Last week we covered the physical exam. This week: the diagnostic evaluation.

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By |2020-03-22T13:31:23-07:00Mar 23, 2020|Cardiovascular, Emergency Medicine|

LVAD Part I: Introduction

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By |2020-03-16T08:39:41-07:00Mar 16, 2020|Cardiovascular, Emergency Medicine|
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