Latest news with #guidelines
Medscape
19 hours ago
- Health
- Medscape
Top Updates in 2025 ACS Management Guidelines
The 2025 American Heart Association/American College of Cardiology Guidelines on the management of acute coronary syndromes (ACS) were finally published recently, marking the first update after an 11-year hiatus. Despite this long gap, most acute care clinicians have remained current on ACS management through the European guidelines and other continuing medical education sources. Still, many of us have been eager to see whether the new US guidelines would contain any surprises or major breakthroughs. For those that have kept up with the literature on accelerated diagnostic protocols, troponins, anticoagulants, and related topics, the new guidelines may not feel groundbreaking. Nonetheless, the publication provided some critical reminders and a few key updates that all acute care providers should know. What follows is a selection of the most important takeaways, in my opinion, for providing acute care to patients presenting with ACS. This is not intended to be a comprehensive review of ACS management or of concepts that are already well-established in current practice. Key Points and Updated Information Posterior MI remains underdiagnosed. Missed or delayed diagnosis of acute posterior myocardial infarction (MI) remains common in acute care, largely because ST-segment elevation (STE) is lacking on the standard 12-lead ECG. Instead, these patients tend to present with ST-segment depression in the right precordial leads V1-V3. The authors remind us that the recommended method of detecting posterior MI is through the use of posterior leads in any patients with concerning symptoms and ST-depression in the right precordial leads. If ≥ 0.5 mm of STE is present in any one of the posterior leads, the diagnosis of acute posterior MI is made and justifies acute reperfusion therapy (ie, thrombolytics or immediate cardiac catheterization/percutaneous coronary intervention). Missed or delayed diagnosis of acute posterior myocardial infarction (MI) remains common in acute care, largely because ST-segment elevation (STE) is lacking on the standard 12-lead ECG. Instead, these patients tend to present with ST-segment depression in the right precordial leads V1-V3. The authors remind us that the recommended method of detecting posterior MI is through the use of posterior leads in any patients with concerning symptoms and ST-depression in the right precordial leads. If ≥ 0.5 mm of STE is present in any one of the posterior leads, the diagnosis of acute posterior MI is made and justifies acute reperfusion therapy (ie, thrombolytics or immediate cardiac catheterization/percutaneous coronary intervention). A normal ECG does not rule out ACS. The authors also remind us that the absence of electrocardiographic findings of ischemia does not rule out ACS. The authors also remind us that the absence of electrocardiographic findings of ischemia does not rule out ACS. Troponin-negative ACS ('unstable angina') still exists. The authors spend some time reviewing the pathophysiology of ACS and its correlation with troponin elevation. In this section, they remind us of a critical point: 'Unstable angina' (ie, troponin-negative ACS) still exists, even in this day of highly sensitive troponins. Just as they have reminded us that a nonischemic ECG does not rule out ACS, a negative troponin does not rule out ACS. They also remind us that even in the setting of a STEMI, a troponin test may be negative if measured within a short time from the onset of symptoms. The authors spend some time reviewing the pathophysiology of ACS and its correlation with troponin elevation. In this section, they remind us of a critical point: 'Unstable angina' (ie, troponin-negative ACS) still exists, even in this day of highly sensitive troponins. Just as they have reminded us that a nonischemic ECG does not rule out ACS, a negative troponin does not rule out ACS. They also remind us that even in the setting of a STEMI, a troponin test may be negative if measured within a short time from the onset of symptoms. Repeat ECGs are essential. The importance of serial ECG testing in patients with concerning symptoms and initially negative ECGs is emphasized. The authors state that 11% of patients ultimately diagnosed with STEMI had an initial ECG that was negative. Therefore, failure to repeat ECGs in this group of patients can result in a significant number of missed STEMIs and, in my experience, has been a common complaint in litigated cases. The importance of serial ECG testing in patients with concerning symptoms and initially negative ECGs is emphasized. The authors state that 11% of patients ultimately diagnosed with STEMI had an initial ECG that was negative. Therefore, failure to repeat ECGs in this group of patients can result in a significant number of missed STEMIs and, in my experience, has been a common complaint in litigated cases. Some patients require urgent catheterization despite the absence of STE. Another common cause of litigation is failure of healthcare providers to remember that there are groups of patients that need immediate cardiac catheterization despite the absence of STE on the ECG. In fact, the guideline indicates that catheterization should be undergone within 2 hours (Class I recommendation). These patients with ACS are categorized as unstable or very high-risk, and they include: Patients in cardiogenic shock. Patients with signs or symptoms of acute heart failure, including new or worsening mitral regurgitation or acute pulmonary edema. Patients with refractory angina. Patients with hemodynamic or electrical instability (eg, sustained ventricular tachycardia or ventricular fibrillation). Another common cause of litigation is failure of healthcare providers to remember that there are groups of patients that need immediate cardiac catheterization despite the absence of STE on the ECG. In fact, the guideline indicates that catheterization should be undergone within 2 hours (Class I recommendation). These patients with ACS are categorized as unstable or very high-risk, and they include: Blood transfusion thresholds remain uncertain. The indication for blood transfusion in patients with ACS has been a source of uncertainty for decades. Although large randomized studies to provide a clear answer are still lacking, the authors suggest (Class IIb) that in patients with ACS and acute or chronic anemia, packed cell transfusions should be provided to achieve a hemoglobin level ≥ 10 g/dL in order to reduce cardiovascular events. Viewpoint The ability to manage ACS in an evidence-based manner is critical to anyone who practices acute care medicine. These most recent US guidelines provide a fairly comprehensive review of the management of ACS, and I recommend a thorough read of the entire publication. However, I would most strongly emphasize knowledge of the points noted above because, in my experience, these have continued to be a source of confusion or missed opportunities to diagnose and properly manage this high-risk group of patients. Amal Mattu, MD, is a professor, vice chair of education, and co-director of the emergency cardiology fellowship in the Department of Emergency Medicine at the University of Maryland School of Medicine in Baltimore. Follow Dr Mattu on X.
Argaam
3 days ago
- General
- Argaam
KSA approves rules for public utility facilities
Deputy Minister of Environment, Water and Agriculture for Agriculture, Hamad Al-Khamshi, approved the guidelines for establishments located at public utility markets for vegetables, fruits, meat, eggs, and fish. The guidelines shall be enforced as of the date of publication, and all relevant parties shall be notified for implementation. The guidelines supersede any previous conflicting regulations, according to Umm Al-Qura official newspaper. Under the guidelines, establishments are required to have air or plastic curtains on external entrance doors, as well as natural or artificial lighting (or both) at the premises. Artificial lighting should not alter the appearance of colors, and its intensity must suit the nature of operations. Light fixtures must be shatter-resistant or protected by covers in areas where they are directly exposed to food, equipment, utensils, or unsealed packaging materials.
RNZ News
7 days ago
- General
- RNZ News
Principals warn Education Ministry instruction on school opening hours 'not feasible'
Principals said secondary schools would struggle to find enough days in a year to operate under the new guidelines. (File photo) Photo: 123RF Secondary principals warn they cannot work with new Education Ministry guidelines that set a higher bar for deciding if schools are "open for instruction" . The ministry recently told schools they would not be considered "open for instruction" if only some year groups were present, or they were only providing supervision. Secondary principals told RNZ it was a serious problem because many secondary schools had a staggered start to the school year, bringing different year groups back on different days, and most allowed their senior students to study from home during secondary school exams at the end of the year. Secondary Principals Association Louise Anaru said if those days were not counted as "open for instruction", schools would not be able to find enough days in the year to operate. The ministry had told schools to continue with their usual practices this year but the new interpretation would apply next year. Asked by RNZ why the change was required it said: "While the regulations have not changed, the guidance has been developed to support consistent teaching and learning across the school system, making sure all students receive the minimum guaranteed time they are entitled to each year. "Further guidance is being developed to provide clarity for secondary schools around end-of-year arrangements and exam-related closures." The ministry did not say whether schools had been misinterpreting the rules and opening for too few days each year. The rules around school opening were based on half-days - periods of two hours or more in which the school was open. Schools had to be open for one half-day before noon and one half-day after noon each day of the school term. Primary schools must be open for at least 382 half-days and secondaries for at least 376 half-days, and no schools could be open for more than 402 half-days. Anaru said the ministry's guidelines would have a big impact on secondary schools. "We have sought legal opinion on it which also concurred that it just wouldn't be possible for secondary schools to comply with these new guidelines. "There's not enough days in the year to be open for instruction using these new guidelines and really it would just create a very confused situation for schools." She said the association's legal advice was that the ministry's interpretation was wrong. "The ministry's guidelines do not comply with the open for instruction requirements as part of the Education Act. It's an interpretation which is just not feasible for schools to implement," she said. Anaru said the association had not discussed whether to take legal action. Burnside High School principal Scott Haines said the new directive would have a huge effect on every secondary school in the country. "The new interpretation will have a seismic impact on both how this school, Burnside High School, operates and on how I think probably just about every other secondary school in New Zealand will operate because it represents a very different position and interpretation than has been the custom and practice for as long as I've been in education, which is now 25 years." Haines said a staggered start to the year was essential for a big school like Burnside. Under the new rules that would have to stop, or count as days outside the normal school year - but that would mean using some of the 10 days a year that teachers could be called back to schools when they were not open for instruction. "We're already leaning on those days with events such as parent interviews in the evenings, open evenings... so there's already a significant call on that resource. If the sense is that we need to rely more heavily on that then we're going to need more days in the collective agreement," he said. The guidance to schools also said teachers' collective agreements required unions to work with school boards to ensure schools remained open for instruction during paid union meetings. NZEI national secretary Stephanie Mills said its members recognised closing primary schools had a significant effect so it arranged its paid meetings accordingly. "We don't believe the situation with paid union meetings is even relevant to that guidance that the ministry's issued about 'open for instruction'. There's no change to the legislation in terms of their rights under the Employment Relations Act to paid union meetings and so we're just going to continue with business as usual," she said. Sign up for Ngā Pitopito Kōrero , a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
The Independent
12-06-2025
- Entertainment
- The Independent
Carnival Cruise Line clarifies ban on handheld fans
Carnival Cruise Line has banned handheld fans from its onboard dance floors due to "safety reasons," according to a guideline letter issued on June 1. The new rules prohibit non-battery-powered fans in nightclubs and on indoor dance floors, while beverages are also not allowed on any dance floor. Battery-powered and electric fans are still permitted on dancefloors and on board, including in passenger cabins, as clarified by Carnival Cruise Lines' senior cruise director, John Heald. Carnival Cruise Line stated that the updated guidelines, which have been part of their standard communications for over two years, aim to support a safe and friendly environment. Other cruise lines, such as Saudi Arabia's Aroya, also have banned items, including scissors, CDs, magazines violating public decency, and alcoholic beverages.
CNA
09-06-2025
- Politics
- CNA
EU working on new guidelines to better protect children online
The European Union is working on new guidelines to protect children online. Lawmakers say the online safety of children is a top priority, but as William Denselow reports from Brussels, stricter guidelines could also worsen tensions with Silicon Valley and the US administration.
