The headliner: Arterial lines are likely unnecessary for critically ill patients with shock
Back when I was an intern in the ICU, arterial line insertion was near universal for patients. But this practice is primarily based on historical precedent rather than high-quality data. The EVERDAC trial was a multicenter, open-label, non-inferiority trial of 1010 patients admitted with shock to the ICU in the past 24 hours. The primary outcome of death from any cause occurred in 34.3% in the noninvasive group and 36.9% in the invasive strategy group (adjusted risk difference -3.2%, 95% CI -8.9% to 2.5%). Hematoma or hemorrhage occurred in 1% in the non-invasive group and 8.2% in the invasive group(!) Said differently, arterial lines cause harm, and relying on good-ol blood pressure cuff measurements alone leads to a similar risk of all-cause mortality.
The hidden gem: For patients presenting with acute ischemic stroke while on an anticoagulant for afib, adding aspirin might be a bad idea
How should we manage patients with an acute ischemic stroke who are already on an anticoagulant (e.g., apixaban) for their atrial fibrillation (link)? Often patients are started on an antiplatelet (e.g., aspirin) and their anticoagulant is continued, but this is based on low-quality data. Enter this multicentre, open-label RCT across 41 sites in Japan from 2016 to 2025. They included patients who had a recent stroke or TIA, afib, and cardiovascular disease. Overall, 316 patients were randomized to combination therapy or monotherapy. The primary outcome of ischemic CV events and major bleeding occurred in 17.8% on combination therapy and 19.6% in the monotherapy group (HR 0.91, 95% CI 0.53-1.55). Bleeding events were more common in the combination group at 19.5% compared to 8.6% in the monotherapy group (HR 2.42, 95% CI 1.23-4.76). While this might suggest that the combination of an anticoagulant plus an antiplatelet is a bad idea, this isn’t exactly a slam dunk as the trial was stopped early after an interim analysis for futility.
The take home points:
[1] For critically ill patients, arterial lines lead to an increased risk of hematoma and a similar risk of 28 day mortality compared to old school blood pressure cuff measurements.
[2] For patients with acute stroke who are already on an anticoagulant for afib, the addition of aspirin increased risk of bleeding without clear benefits.