Zworth Reading

Meta-Analysis of Norepinephrine vs Epinephrine After Cardiac ArrestKnowledge translation — appraisal of primary literature

REBEL EM  ·  LOE 1 (meta-analysis) — but underlying studies are observational

REBEL EM reviews a meta-analysis from 2025 examining whether norepinephrine reduces recurrent cardiac arrest compared to epinephrine post-ROSC. The underlying evidence is observational, so while the pooled analysis suggests a signal favoring norepinephrine, this remains hypothesis-generating rather than practice-changing.

Bottom line: Very thorough review of a meta-analysis on an interesting topic. With the caveat that data is observational, there is definitely a signal here that norepinephrine may be preferable post-ROSC and reduces risk of re-arrest. Worth reading both the original paper and this review.

2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome

American Heart Association / American College of Cardiology / American Diabetes Association / American Society of Nephrology

• Formalizes 'CKM syndrome' as the interrelated continuum of obesity, type 2 diabetes, CKD, and cardiovascular disease and replaces the 2013 AHA/ACC/TOS obesity guideline.
• CKM staging (0-4) is now standard language: patients with CKD + DM + CVD are flagged as Stage 4 and warrant aggressive secondary prevention. Useful framing when handing off complex multimorbid patients.
• GLP-1 receptor agonists (semaglutide, tirzepatide) and SGLT2 inhibitors are now recommended for cardiovascular and renal risk reduction independent of glycemic control. We will continue to see more ED patients on these medications for a variety of indications.
• Reinforces that incidental findings of CKD, microalbuminuria, or new T2DM in an ED workup should prompt PCP follow-up with a CKM lens, not just a single-disease referral.
• Most content is outpatient/preventive — direct ED-actionable items are limited.

GRADE methodology, comprehensive evidence synthesis through April 2025. Strong recommendations are generally well-supported, though much of the integrative CKM framework is consensus-driven rather than RCT-derived.

Conflicts with existing guidance: Replaces and retires the 2013 AHA/ACC/TOS obesity guideline. Largely aligns with recent ADA Standards of Care and KDIGO CKD guidelines.

Bottom line: Mostly an outpatient guideline, but worth knowing CKM staging exists and that GLP-1s/SGLT2s are now first-line cardiorenal protective agents.

Recurrent Venous Thromboembolism During Anticoagulation: Diagnosis, Systematic Evaluation, and ManagementLOE 5 (Narrative review / expert synthesis)

Blood / Thrombosis (review)  ·  Hematology / Thrombosis

N/A — clinical review article.

Comprehensive review of recurrent VTE in patients already on therapeutic anticoagulation. Highest-risk populations: active cancer (especially metastatic), antiphospholipid syndrome (particularly triple-positive), and the early treatment period (first 6 months after initial VTE). In a patient with known PE and new/worsening respiratory symptoms remember to work up for alternate causes.  Diagnostic workup should not rely on D-dimer as anticoagulants can lead to false negatives.

Authoritative review from a thrombosis group, useful as a practical framework. Key point for EM: do not assume a patient on anticoagulation cannot have a new clot. Recurrent VTE on therapeutic AC is a real and underrecognized phenomenon, particularly in the first 6 months and in cancer patients. Management of confirmed breakthrough VTE typically involves switching agents (e.g., DOAC to LMWH) rather than just increasing the dose, and warrants hematology involvement.

Bottom line: Recognize the high-risk patient: active cancer, APS, or within the first 6 months of treatment for an index VTE. New symptoms in these patients warrant imaging even on therapeutic anticoagulation. Don't anchor on 'they're already anticoagulated', as treatment failure is real. Confirmed breakthrough VTE usually means switching anticoagulant class, and speaking with hematology.

How Would You Manage This Patient With Iron Deficiency Anemia? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterLOE 5 (Expert review / Grand Rounds)

Annals of Internal Medicine  ·  Hematology / Internal Medicine

How should iron deficiency and IDA be diagnosed and managed in adults?

Two hematologists debate diagnosis and management. Key takeaways: no single ferritin cutoff is perfectly sensitive — 30 µg/L is commonly used but still misses many patients (WHO's <15 µg/L cutoff misses up to 50%). GI workup identifies a cause in ~90% of adults with IDA but yield is much lower in premenopausal women (gastric cancer 0.06%, colon cancer 0.27%). Ferrous sulfate 325 mg nightly is the recommended starting regimen; enteric-coated formulations are more expensive and less effective. Vitamin C does not improve absorption. Every-other-day dosing is based on a flawed study and not actually superior to daily.

Honest, evidence-grounded discussion. Most relevant to EM: think about IDA in patients with compatible symptoms even if Hb is normal, and consider ordering iron studies. Recognizing IDA and starting iron is appropriate ED work.

Bottom line: Key ED take-homes: (1) No clean cutoff for IDA — 30 µg/L is commonly used but probably still misses people. (2) GI workup identifies a cause in 90% of adults with IDA; yield in premenopausal women is much lower. (3) Recommended starting regimen is ferrous sulfate 325 mg nightly. Enteric-coated agents are more expensive and less effective. 

Hospital Policy of Tranexamic Acid to Reduce Transfusion in Major Noncardiac Surgery (TRACTION Trial)LOE 2 — Cluster-randomized crossover trial

The New England Journal of Medicine

Why it matters to EPs: We already use TXA for a variety of indications and keeping up with the literature about efficacy and risk profile is important. This trial extends the safety and effectiveness signal into a much broader surgical population, including a large oncologic cohort historically excluded from TXA trials.

8,273 patients across 10 Canadian hospitals undergoing major noncardiac surgery (60.5% oncologic). Hospital-wide policy of routine intraoperative TXA (1 g at start + 1 g before closure) reduced red cell transfusion from 9.8% to 7.4% (RR 0.73, NNT ~37). 90-day VTE was identical at 2.1% in both groups. In the cancer subgroup specifically, no increased VTE signal (2.4% vs 2.6%).

Confirms and extends POISE-3, with a more diverse surgical population and meaningful inclusion of oncologic surgery, historically the population where TXA has been most controversial due to thrombosis concerns. The transfusion benefit is real but modest (ARR 2.4%). The reassuring VTE safety signal in cancer patients is arguably the most important contribution.

Bottom line: TXA continues to accumulate evidence as a safe and modestly effective antifibrinolytic across surgical and non-surgical bleeding contexts. Most important takeaway for EM: the cancer-patient VTE concern that limited TXA use historically appears not to be reflected in this cohort. No direct ED algorithm change, but supports continued use in trauma, postpartum, and bleeding indications