R&R In The FASTLANE 150

Welcome to the 150th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the : Overview; Archives and Contributors

This Edition’s R&R Hall of Famer

Bønaa KH, Mannsverk J, et al. Drug-Eluting or Bare-Metal Stents for Coronary Artery Disease. New England Journal of Medicine. 2016. PMID: 27572953

• The NORSTENT (Norwegian Coronary Stent) trial was a multi-centre, randomised controlled trial enrolling 9013 patients with stable or unstable coronary artery disease undergoing PCI with impantation of either a drug eluting or bare metal stent. The study did not find a significant difference between contemporary drug-eluting stents and bare-metal stents in the rates of death from any cause or nonfatal spontaneous myocardial infarction during 6 years of follow-up. There was a statistically significant reduction in the rate of repeat revascularization in the group receiving drug-eluting stents, with persistence of this effect over 6 years.
• Recommended by: Nudrat Rashid

Davidson BL. The association of direct thrombin inhibitor anticoagulants with cardiac thromboses. Chest. 2015. PMID: 25254608

• This paper is a commentary, so the level of evidence is not great but is fairly well substantiated and is pretty important to discuss the points it makes. NOACs have been associated with a lower risk of intracerebral bleed and equal or slightly higher risk of GI bleeding, while being effective in achieving antithrombosis. What this article describes is a significant increase on endothelial dysfunction, cardiac thrombosis and subsequent major adverse cardiac outcomes, including deaths. The author makes the point of not prescribing direct thrombin inhibitors and continue to use coumarins. 
• Recommended by: Daniel Cabrera

Miller M, et al. Hemodynamic Response After Rapid Sequence Induction With Ketamine in Out-of-Hospital Patients at Risk of Shock as Defined by the Shock Index. Ann Emerg Med. 2016. PMID: 27130803

•  This article delves into the hemodynamic effects (using shock index) of ketamine for RSI. In the small sample of high shock index patients (n = 31) they found minimal change in SBP. The data has inherent flaws in an uncontrolled study but a good read to help gauge expectations in RSI.
• Recommended by: Anand Swaminathan

Krauser DG, et al. Effect of body mass index on natriuretic peptide levels in patients with acute congestive heart failure: a ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) substudy. Am Heart J. 2005. PMID:15990762 

• A good reminder of an important clinical take away that I don’t hear discussed often in the EM community….as BMI increases BNP (and pro-BNP) decreases. As a recent case reminded me, the limited clinical utility of BNP testing in general is exacerbated in the patient population which can be the most difficult to examine: the obese patient. This study demonstrated the decrease of both BNP and pro-BNP in obese patients presenting to the ED with CHF exacerbations. 10-20% were below the clinical cutoff points for the test. A much more useful test for these patients…ultrasound!
• Recommended by: Jeremy Fried

Body R, Mueller C, et al. The use of very low concentrations of high sensitivity troponin T to rule out acute myocardial infarction using a single blood test. Acad Emerg Med. 2016. PMID: 27178492

•  Increasingly sensitive troponin assays can detect increasingly small amounts of troponin – naturally. Interestingly, this means we seem to be hitting a limit to their performance characteristics because we’re also picking up very tiny missed AMIs as what would previously been a “true negative”.
• Recommended by: Ryan Radecki
• Read more: The High-Sensitivity Troponin Ennui (EM lit of note)

Gagyor I, et al. Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2015. PMID: 26559436

•  This topic is a mess – maybe one of our smart readers can sort it out for us. The best evidence to date was that antivirals do not improve outcomes in Bell’s palsy. This is an updated Cochrane review that adds 3 new studies and a total of 300 patients to the prior review, and it reaches a new conclusion: antivirals work. The strange thing here is that the same authors published the same review 6 months earlier, and at that time it included 1 extra trial, and the conclusion was that antivirals don’t work. I think the best take away is: the trials are all small and low quality, so we really don’t know the answer. Furthermore, harms are almost certainly under-reported (only 3 or 10 trials mention them), so there is no way we can adequately discuss harms and benefits with our patients at this point.
• Recommended by: Justin Morgenstern