Evidence Based Medicine is Easy

[@zachgraves3356]

Awesome video, I've been really enjoying this channel! Would love to see a video on Heparin in NSTEMI/unstable angina- I had never previously heard of the harms of it outweighing the benefits. I just read all your previous articles on it and find it all very fascinating. I think it is quite difficult for most physicians to go against long standing guidelines that are common practice (such as the AHA/ACC recommending anticoagulation with heparin; Class I recommendation). To clarify, does what you're discussing and your approach apply to all anticoagulation in NSTEMI/unstable angina or just the use of heparin? What about enoxaparin or fondaparinux? You stated in your previous article on the topic that you don’t prescribe heparin in NSTEMI or unstable angina patient. From the evidence you provide, I can see why that would be reasonable if you are treating with a non-invasive approach. I'd love to hear you expand a bit more on the fact that most of the studies were done in the pre-catheterization era. I'd wonder if there would still be benefit when treating with an invasive strategy, with heparin being a temporary bridge to definitive revascularization. Are you still not using heparin in these cases? Also, in your center when you don't give heparin in your NSTEMI/unstable angina patients do you find the cardiologists just end up giving it when they assess/admit the patient?

[@First10EM]

Heparin is definitely in my list for a future video. I will try to incorporate your questions when I get there. In terms of efficacy, there isn't any difference between unfractionated heparin and all the other options, so when I refer to 'heparin', I am including enoxaparin, fonda, and everything else. There is a second blog post on heparin for STEMI / during catheterization, and I don't think it is needed there either: first10em.com/heparin-in-stemi-and-pci/ The hardest part of EBM in emergency medicine is that we co-manage almost all of our patients. I have this conversation repeatedly with medicine and cardiology. For the most part, doctors seem uncomfortable departing from guidelines, even through we know guidelines are flawed and only meant to guide our practice, not be slavishly followed. A huge part of my career has been dedicated to trying to convince people to move from guideline based care to science based care.

[@jokullsindrigunnarsson8084]

great video. i just never know where to start. do i just start with any new issue of a top journal? is there a way to see trending papers?

[@First10EM]

There are a ton of options. Picking the top journal for your specialty is one approach, and it works pretty well if you are just getting started. However, I think you can probably do better than that. There are tons of resources that will filter through the literature for you, and just bring the most important papers to your attention. There are InfoPOEMS, The NEJM Journal Watch, or a bunch of FOAMed sites like the Skeptics Guide to Emergency Medicine, First10EM, REBELEM. The nice thing about these filtering services is most offer some form of critical appraisal as well, so as you are getting started you can compare your thoughts about a paper with someone else's to get a sense of things you might be overlooking. There should be an updated version of the BroomeDocs journal club podcast coming to this channel soon, so make sure you subscribe :)