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