The edition · Top Clinical Updates
A ruled-out troponin still carries risk, and a CHA2DS2-VASc of 1 is not nothing
Routine CT coronary angiography after a ruled-out chest pain changed nothing over three years; physiotherapists ran the musculoskeletal side of five emergency departments an hour faster and cheaper; and a Korean trial finally randomises the anticoagulation decision everyone guesses at.
The edition in brief
Four findings for a clinician of any specialty. TARGET-CTCA randomised 3170 patients in 14 UK emergency departments who had myocardial infarction ruled out but a maximum high-sensitivity troponin above 5 ng/L to outpatient CT coronary angiography or standard care. After a median 3.0 years, myocardial infarction or cardiac death had occurred in 7.1% versus 7.3% (adjusted hazard ratio 0.95, 95% CI 0.73 to 1.23, P=0.71). The imaging found things; it did not change outcomes. The risk itself is the finding worth keeping: 7% of these ruled-out patients had a hard cardiac event within three years. A JAMA evidence review of 75 studies sets out what to expect from RSV immunisation this season: vaccine effectiveness against RSV hospitalisation in older adults 83.3% (95% CI 42.9 to 96.9), maternal vaccination at 32 to 36 weeks 51.0% to 70.0% against infant hospitalisation, nirsevimab 63.6% to 93.0%, with protection in older adults appearing to fall in later seasons and no confirmed excess of Guillain-Barre syndrome across three randomised trials. RESHAP-ED randomised 1491 adults with uncomplicated musculoskeletal presentations at five Australian emergency departments to physiotherapist-led or usual physician-led care: mean length of stay 2.4 h versus 3.4 h, a difference of 1.0 h (95% CI 0.8 to 1.2), with no excess of adverse events and lower costs. The edition closes with SINGLE-AF, which randomised 1803 patients with atrial fibrillation and a CHA2DS2-VASc score of 1 in men or 2 in women to a direct oral anticoagulant or nothing. The composite endpoint fell from 1.5% to 0.5% at 24 months, hazard ratio 0.31 (95% CI 0.10 to 0.94), on 17 events in total.
What to promise about RSV immunisation this season
RSV vaccination cut hospitalisation in older adults by about 83%, maternal vaccination at 32 to 36 weeks by 51% to 70% for infant hospitalisation, and nirsevimab by 64% to 93% - with protection in older adults probably weaker in later seasons.
Imaging the ruled-out chest pain does not change what happens next
In patients whose myocardial infarction has been ruled out but whose troponin is above 5 ng/L, routine outpatient CT coronary angiography did not reduce myocardial infarction or cardiac death over three years (7.1% vs 7.3%, adjusted HR 0.95, 95% CI 0.73 to 1.23).
Physiotherapists took an hour off the musculoskeletal emergency visit
Physiotherapist-led care for uncomplicated musculoskeletal presentations cut mean emergency department stay from 3.4 h to 2.4 h with no excess of adverse events and lower costs, in a tightly screened group that was about a third of those assessed.
Write down the troponin number, not just the word 'negative'
Put the actual peak troponin value and the assay in the discharge summary, not just 'ACS excluded' - a detectable troponin with infarction ruled out marks a patient who needs risk factor management, not more imaging.
Anticoagulate the atrial fibrillation patient with a CHA2DS2-VASc of 1
In atrial fibrillation with a CHA2DS2-VASc of 1 in men or 2 in women, a direct oral anticoagulant cut the 24-month composite of stroke, embolism, major bleeding or cardiovascular death from 1.5% to 0.5% (HR 0.31, 95% CI 0.10 to 0.94) - the first randomised support for a decision guidelines left open.
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