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Introduction: Hyperkalemia, a potentially life-threatening electrolyte disturbance, is commonly encountered in the Emergency Department (ED). However, the frequency of factitious hyperkalemia, an artificially elevated potassium level in hyperkalemic ED patients, is unknown. This study aims to detect the rate of factitious hyperkalemia among patients with a potassium concentration of ≥5.0 mmol/l in an all-comer ED population., Methods: This retrospective, monocentric chart review analyzed data of 2,440 ED patients who presented with a potassium concentration of ≥5.0 mmol/L in their initial whole blood or plasma sample, who also underwent a repeat potassium measurement on the same day. Two groups were established based on potassium levels in the initial and repeat blood tests: 1) True hyperkalemia, characterized by consistently elevated potassium levels in both the initial and repeat samples; and 2) Factitious hyperkalemia, defined by an elevated initial potassium level while the repeat blood test showed a normal potassium level. A subset of factitious hyperkalemia was spurious hyperkalemia. In spurious hyperkalemia, the initial blood sample showed an elevated potassium level with evidence of hemolysis, but a repeat test revealed a normal potassium level without evidence of hemolysis., Results: Of the 2,440 patients, 1,576 (65%) had true hyperkalemia and 864 (35%) factitious hyperkalemia. Among the 864 patients with factitious hyperkalemia, 597 (69%) displayed hemolysis in their initial blood sample, indicating spurious hyperkalemia due to in-vitro hemolysis., Conclusion: These data show that about one third of all hyperkalemic blood samples drawn in the ED were due to factitious hyperkalemia. The leading cause of factitious hyperkalemia was spurious hyperkalemia due to in-vitro hemolysis., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. This work was supported by scientific funds of the Emergency Department of the University Hospital Basel. There are no other conflicts of interest or sources of funding to declare.

Background: Prompt differential diagnosis of wide QRS complex tachycardia (WCT) is crucial to patient management. However, distinguishing ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with wide QRS complexes remains problematic, especially for nonelectrophysiologists., Objectives: This study aimed to develop a simple-to-use algorithm with integration of clinical and electrocardiographic (ECG) parameters for the differential diagnosis of WCT., Methods: The 12-lead ECGs of 206 monomorphic WCTs (153 VT, 53 SVT) with electrophysiology-confirmed diagnoses were analyzed. In the novel Basel algorithm, VT was diagnosed in the presence of at least 2 of the following criteria: 1) clinical high risk features; 2) lead II time to first peak >40 ms; and 3) lead aVR time to first peak >40 ms. The algorithm was externally validated in 203 consecutive WCT cases (151 VT, 52 SVT). Its' diagnostic performance and clinical applicability were compared with those of the Brugada and Vereckei algorithms., Results: The Basel algorithm showed a sensitivity, specificity, and accuracy of 92%, 89%, and 91%, respectively, in the derivation cohort and 93%, 90%, and 93%, respectively, in the validation cohort. There were no significant differences in the performance characteristics between the 3 algorithms. The evaluation of the clinical applicability of the Basel algorithm showed similar diagnostic accuracy compared with the Brugada algorithm (80% vs 81%; P = 1.00), but superiority compared with the Vereckei algorithm (72%; P = 0.03). The Basel algorithm, however, enabled a faster diagnosis (median 36 seconds vs 105 seconds for the Brugada algorithm [P = 0.002] and 50 seconds for the Vereckei algorithm [P = 0.02])., Conclusions: The novel Basel algorithm based on simple clinical and ECG criteria allows for a rapid and accurate differential diagnosis of WCT., Competing Interests: Funding Support and Author Disclosures Dr Schaer has received personal fees from Medtronic. Dr Kühne has received grants from the Swiss National Science Foundation, the Swiss Heart Foundation, Daiichi-Sankyo, Bayer, Pfizer BMS, and Boston Scientific; and has received personal fees from Bayer, Boehringer Ingelheim, Pfizer BMS, Daiichi-Sankyo, Medtronic, Biotronik, Boston Scientific, and Johnson & Johnson, all outside the submitted work. Dr Henrikson has received fellowship support from Abbott, Boston Scientific, and Medtronic; and has served as chair of the clinical endpoints committee for Biotronik. Dr Sticherling has received grants from Biosense-Webster; and has received lecture fees from Abbott, Medtronic, Biosense-Webster, Boston Scientific, Microport, and Biotronik. Dr Reichlin has received speaker/consulting honoraria or travel support from Abbott/SJM, AstraZeneca, Brahms, Bayer, Biosense-Webster, Biotronik, Boston-Scientific, Daiichi-Sankyo, Medtronic, Pfizer BMS, and Roche, all for work outside the submitted study; and has received support for his institution’s fellowship program from Abbott/SJM, Biosense-Webster, Biotronik, Boston-Scientific, and Medtronic for work outside the submitted study. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: We aimed to investigate the association of clinically overt and silent brain lesions with cognitive function in atrial fibrillation (AF) patients., Methods and Results: We enrolled 1227 AF patients in a prospective, multicentre cohort study (Swiss-AF). Patients underwent standardized brain magnetic resonance imaging (MRI) at baseline and after 2 years. We quantified new small non-cortical infarcts (SNCIs) and large non-cortical or cortical infarcts (LNCCIs), white matter lesions (WML), and microbleeds (Mb). Clinically, silent infarcts were defined as new SNCI/LNCCI on follow-up MRI in patients without a clinical stroke or transient ischaemic attack (TIA) during follow-up. Cognition was assessed using validated tests. The mean age was 71 years, 26.1% were females, and 89.9% were anticoagulated. Twenty-eight patients (2.3%) experienced a stroke/TIA during 2 years of follow-up. Of the 68 (5.5%) patients with ≥1 SNCI/LNCCI, 60 (88.2%) were anticoagulated at baseline and 58 (85.3%) had a silent infarct. Patients with brain infarcts had a larger decline in cognition [median (interquartile range)] changes in Cognitive Construct score [-0.12 (-0.22; -0.07)] than patients without new brain infarcts [0.07 (-0.09; 0.25)]. New WML or Mb were not associated with cognitive decline., Conclusion: In a contemporary cohort of AF patients, 5.5% had a new brain infarct on MRI after 2 years. The majority of these infarcts was clinically silent and occurred in anticoagulated patients. Clinically, overt and silent brain infarcts had a similar impact on cognitive decline., Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02105844, https://clinicaltrials.gov/ct2/show/NCT02105844., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology.)

This review serves as a synopsis of multimodality imaging in cardiac amyloidosis (CA), which is a disease characterized by deposition of misfolded protein fragments in the heart. It emphasizes and summarizes the diagnostic possibilities and their prognostic values. In general, echocardiography is the first diagnostic tool in patients with an identified systemic disease or unclear left ventricular hypertrophy. Several echocardiographic parameters will raise suspicion and lead to further testing. Cardiac magnetic resonance and scintigraphy with bone avid radiotracers are crucial for diagnosis of CA and even enable a distinction between different subtypes. The subject is illuminated with established guidelines and innovative recent publications to further improve early diagnosis of cardiac amyloidosis in light of current treatment options.

Background: Drug-coated balloons (DCB) are a novel therapeutic strategy for small native coronary artery disease. However, their safety and efficacy is poorly defined in comparison with drug-eluting stents (DES)., Methods: BASKET-SMALL 2 was a multicentre, open-label, randomised non-inferiority trial. 758 patients with de-novo lesions (<3 mm in diameter) in coronary vessels and an indication for percutaneous coronary intervention were randomly allocated (1:1) to receive angioplasty with DCB versus implantation of a second-generation DES after successful predilatation via an interactive internet-based response system. Dual antiplatelet therapy was given according to current guidelines. The primary objective was to show non-inferiority of DCB versus DES regarding major adverse cardiac events (MACE; ie, cardiac death, non-fatal myocardial infarction, and target-vessel revascularisation) after 12 months. The non-inferiority margin was an absolute difference of 4% in MACE. This trial is registered with ClinicalTrials.gov, number NCT01574534., Findings: Between April 10, 2012, and February 1, 2017, 382 patients were randomly assigned to the DCB group and 376 to DES group. Non-inferiority of DCB versus DES was shown because the 95% CI of the absolute difference in MACE in the per-protocol population was below the predefined margin (-3·83 to 3·93%, p=0·0217). After 12 months, the proportions of MACE were similar in both groups of the full-analysis population (MACE was 7·5% for the DCB group vs 7·3% for the DES group; hazard ratio [HR] 0·97 [95% CI 0·58-1·64], p=0·9180). There were five (1·3%) cardiac-related deaths in the DES group and 12 (3·1%) in the DCB group (full analysis population). Probable or definite stent thrombosis (three [0·8%] in the DCB group vs four [1·1%] in the DES group; HR 0·73 [0·16-3·26]) and major bleeding (four [1·1%] in the DCB group vs nine [2·4%] in the DES group; HR 0·45 [0·14-1·46]) were the most common adverse events., Interpretation: In small native coronary artery disease, DCB was non-inferior to DES regarding MACE up to 12 months, with similar event rates for both treatment groups., Funding: Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung, Basel Cardiovascular Research Foundation, and B Braun Medical AG., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The treatment of coronary small vessel disease (SVD) remains an unresolved issue. Drug-eluting stents (DES) have limited efficacy due to increased rates of instent-restenosis, mainly caused by late lumen loss. Drug-coated balloons (DCB) are a promising technique because native vessels remain structurally unchanged. Basel Stent Kosten-Effektivitäts Trial: Drug-Coated Balloons vs. Drug-Eluting Stents in Small Vessel Interventions (BASKET-SMALL 2) is a multicenter, randomized, controlled, noninferiority trial of DCB vs DES in native SVD for clinical endpoints. Seven hundred fifty-eight patients with de novo lesions in vessels <3 mm in diameter and an indication for percutaneous coronary intervention such as stable angina pectoris, silent ischemia, or acute coronary syndromes are randomized 1:1 to angioplasty with DCB vs implantation of a DES after successful initial balloon angioplasty. The primary endpoint is the combination of cardiac death, nonfatal myocardial infarction, and target-vessel revascularization up to 1 year. Secondary endpoints include stent thrombosis, Bleeding Academic Research Consortium (BARC) type 3 to 5 bleeding, and long-term outcome up to 3 years. Based on clinical endpoints after 1 year, we plan to assess the noninferiority of DCB compared to DES in patients undergoing primary percutaneous coronary intervention for SVD. Results will be available in the second half of 2018. This study will compare DCB and DES regarding long-term safety and efficacy for the treatment of SVD in a large all-comer population., (© 2018 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.)

Competing Interests: Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

Background: Arrhythmia recurrence after atrial fibrillation (AF) ablation remains high and requires repeat interventions in a substantial number of patients. We assessed the value of conventional and 3-D echocardiography to predict AF recurrence., Methods and Results: Consecutive patients undergoing AF ablation by means of pulmonary vein isolation were included in a prospective registry. Echocardiograms were obtained prior to the ablation procedure, and analyzed offline in a standardized manner, including 3-D left atrial (LA) volumetry and determination of LA function and sphericity. The primary endpoint, AF recurrence (>30 seconds) between 3 to 12 months after AF ablation, was independently adjudicated. We included 276 patients (73% male, mean age 59.9 ± 9.9 years). Paroxysmal and persistent AF were present in 178 (64%) and 98 (36%) patients, respectively. Mean left ventricular ejection fraction and indexed LA volume in 3-D (LAVI) were 52 ± 12% and 42 ± 13 mL/m 2 , respectively. AF recurrence was observed in 110 (40%) patients after a single procedure. Median (interquartile range) time to AF recurrence was 123 (92; 236) days. In multivariable Cox regression models, the only predictors for AF recurrence were the minimal, maximal, and indexed 3-D LA volumes, P = 0.024, P = 0.016, and P = 0.014, respectively. Quartile specific analysis of 3-D LAVI showed an HR of 1.885 (95%CI 1.066-3.334; P for trend = 0.015) for the highest compared to the lowest quartile., Conclusion: Our results show the important role of LA volume for the long-term freedom from arrhythmia after AF ablation. These data also highlight the potential of 3-D echocardiography in this context and may facilitate patient selection for AF ablation., (© 2017 Wiley Periodicals, Inc.)

Objective: Electrical injuries are challenging to assess and current guidelines are based on few studies and case reports. Recommendations on cardiac monitoring were published for certain risk factors, but indications for hospital observation are less clear. Furthermore, the risk of late arrhythmias is not known. Therefore, we aimed to assess possible cardiac complications, including death and immediate or delayed dysrhythmia, after an electrical accident in a sample of patients presenting to the Emergency Department (ED)., Methods: Medical records of patients presenting to the ED of the University Hospital Basel, Switzerland, during 2004-2013 were retrospectively reviewed. Follow-up in terms of the survival of these patients was performed through hospital databases, and direct contact with patients and caregivers. The primary endpoint was in hospital mortality and mortality within 10, 30, and 90 days, respectively. For our secondary endpoint, we investigated patient charts for the occurrence of dysrhythmias and laboratory findings., Results: During the study period, a total of 240 patients were identified. Twelve patients were lost to follow-up. Initial ECG was performed in 234 (97.5%) patients and 149 (62.1%) patients received cardiac monitoring. During the time of monitoring, four dysrhythmias (sinus bradycardia, two ventricular premature beats, and atrial fibrillation) were observed. All patients survived, and no potential late serious dysrhythmia requiring a medical intervention was recorded., Conclusion: No cardiac complications occurred during ED stay or during the 90-day follow-up period. Therefore, the need for continued cardiac monitoring after electrical injury is not supported by our data.

Introduction: Left atrial (LA) enlargement is an important risk factor for incident stroke and a key determinant for the success of rhythm control strategies in patients with atrial fibrillation (AF). However, factors associated with LA volume in AF patients remain poorly understood., Methods: Patients with paroxysmal or persistent AF were enrolled in this study. Real time 3-D echocardiography was performed in all participants and analyzed offline in a standardized manner. We performed stepwise backward linear regression analyses using a broad set of clinical parameters to determine independent correlates for 3-D LA volume., Results: We included 210 patients (70.9% male, mean age 61±11years). Paroxysmal and persistent AF were present in 95 (45%) and 115 (55%) patients, respectively. Overall, 115 (55%) had hypertension, 11 (5%) had diabetes, and 18 (9%) had ischemic heart disease. Mean indexed LA volume was 36±12ml/m2. In multivariable models, significant associations were found for female sex (β coefficient -10.51 (95% confidence interval (CI) -17.85;-3.16), p = 0.0053), undergoing cardioversion (β 11.95 (CI 5.15; 18.74), p = 0.0006), diabetes (β 14.23 (CI 2.36; 26.10), p = 0.019), body surface area (BSA) (β 34.21 (CI 19.30; 49.12), p<0.0001), glomerular filtration rate (β -0.21 (CI -0.36; -0.06), p = 0.0064) and plasma levels of NT-pro brain natriuretic peptide (NT-proBNP) (β 6.79 (CI 4.05; 9.52), p<0.0001), but not age (p = 0.59) or hypertension (p = 0.42). Our final model explained 52% of the LA volume variability., Conclusions: In patients with AF, the most important correlates with LA volume are sex, BSA, diabetes, renal function and NT-proBNP, but not age or hypertension. These results may help to refine rhythm control strategies in AF patients., Competing Interests: The authors have declared that no competing interests exist.

Objectives: The aim of this study was to investigate the long-term effect of a teaching intervention designed to reduce undertriage rates in older ED patients. Further, to test the hypothesis that non-adherence to the Emergency Severity Index (ESI) triage algorithm is associated with undertriage. Additionally, to detect patient related risk factors for undertriage., Methods: Pre-post-test design. The study sample consisted of all patients aged 65 years or older presenting to the ED of an urban tertiary and primary care center in the study periods. A teaching intervention designed to increase adherence to the triage algorithm. To assess, if the intervention resulted in an increase of factual knowledge, nurses took a test before and immediately after the teaching intervention. Undertriage rates were assessed one year after the intervention and compared to the pre-test period., Results: In the pre-test group 519 patients were included, and 394 in the post-test-group. Factual knowledge among triage nurses was high already before the teaching intervention. Prevalence of undertriaged patients before (22.5%) and one year after the intervention (24.2%) was not significantly different (χ2 = 0.248, df = 1, p = 0.619). Sex, age, mode of arrival, and type of complaint were not identified as independent risk factors for undertriage. However, undertriage rates increased with advancing age. Adherence to the ESI algorithm is associated with correct triage decisions., Conclusions: Undertriage of older ED patients remained unchanged over time. Reasons for undertriage seem to be more complex than anticipated. Therefore, additional contributing factors should be addressed.

Background: Limited data are available on the accuracy of quantification methods for left atrial (LA) volumes using two-dimensional (2D) and particularly real-time three-dimensional echocardiographic (RT3DE) methods in comparison with a reference standard. The aim of this study was to perform a head-to-head comparison between 2D and RT3DE methods with magnetic resonance imaging (MRI) as the reference standard., Methods: LA volumes derived from 2D echocardiographic methods (i.e., biplane modified Simpson's, biplane area-length, and prolate ellipse methods) and from RT3DE methods (i.e., 4D LA Analysis and QLAB) in 60 consecutive patients were compared with MRI measurements. Offline analysis time was recorded., Results: The biplane modified Simpson's and area-length methods showed good intraclass correlations with MRI for maximum (r = 0.70 and r = 0.69, P < .001) and minimum (r = 0.83 and r = 0.82, P < .001) volumes. Although RT3DE methods led to moderate increases in correlations for maximum (r = 0.94 and 0.70, P < .001) and minimum (r = 0.95 and r = 0.90, P < .001) volumes and narrower Bland-Altman limits of agreement than 2D echocardiographic methods, offline analysis time was higher for RT3DE (155-161 vs 103-144 sec). Compared with MRI, maximum and minimum LA volumes were underestimated by -4.7% and -8.9%, respectively, using 4D LA Analysis, by -15.7% and -14.9% using QLAB, by -12.3% and -4.4% using the biplane Simpson's method, by -13.7% and -6.8% using the area-length method, and by -48.2% and -50.5% using the prolate ellipse method., Conclusions: The biplane Simpson's and area-length methods offer reasonable accuracy for LA chamber quantification across a broad range of volumes, while RT3DE methods lead to a moderate improvement in accuracy at the cost of more elaborate offline analysis., (Copyright © 2013 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

Objectives: Although pain is one of the most common presenting complaints in the Emergency Department (ED), pain management is often inadequate. Pain management protocols have been shown to be useful. The objective of this study was to assess the adherence to an already implemented pain management protocol in an urban ED., Methods: Secondary analysis of a prospective single centre cohort study on patient preferences for analgesia in the ED. Patient charts were reviewed with a focus on selection, timing and dosage of analgesics according to a visual analogue scale (VAS) on arrival and during the ED stay., Results: Three hundred and thirty-seven patient charts were reviewed. The adherence to the implemented pain management protocol was 42% at the time of initial evaluation and 43% during the course of therapy in all patients. Forty-two percent of the study population were discharged with at least moderate pain. However, 43% of the patients discharged with pain did not request analgesics., Conclusions: The benefits of pain management protocols are proven. However, adherence to these protocols needs to be monitored regularly in order to optimise pain management.

Aim: To describe the disease burden, clinical pattern and outcome of influenza-related cases presenting to a Swiss Emergency Department (ED), during the first wave of the 2009 pandemic., Methods: Retrospective analysis of prospectively collected data at the University Hospital of Basel, Switzerland. All patients presenting to the ED with influenza-like symptoms from June 1 to October 23, 2009, were studied. Rate of hospitalisation, demographic characteristics, symptoms, microbiological diagnoses and complications of influenza infection were analysed., Results: One tenth (808 of 8356 patients) of all non-trauma ED presentations, during the study period, were a result of suspected influenza-related illness. Influenza A/H1N1v infection accounted for 5% of these presentations. Patients aged 50 years or less accounted for 87% of these presentations and for 100% of A/H1N1v infection. The highest detection rate of A/H1N1v-infection occurred in July, and the highest rate of clinical presentations occurred in August 2009. Underlying medical disease was observed in 14% of all patients. The presence of fever, cough and myalgia was the prime clinical predictor for the presence of A/H1N1v infection. 16% of patients with this triad suffered from A/H1N1v., Conclusion: Suspected A/H1N1v infection contributed to a considerable health care burden in Switzerland. However, the rate of true positivity was low (5%), hospitalisations rare (5%), and mortality did not occur. Therefore, the first wave of the A/H1N1v pandemic in Switzerland was rather media "hype" than real threat.