Risk stratification in the patient with non ST segment elevation acute coronary syndrome

Patients hospitalized with unstable angina (UA) or with a non-ST segment elevation myocardial infarct (NSTEMI) are at increased risk of suffering refractory angina, recurrent myocardial infarct (MI), and death. These patients need to be evaluated more aggressively. According to the last published guidelines (2002) of UA/NSTEMI by the ACC/AHA Task Force, these patients should be categorized in a risk scale as: low, intermediate or high. This should be done in the initial evaluation, which includes: medical history, physical exam, an electrocardiogram (ECG) and cardiac markers. The TIMI risk score should also be used as complementary in this risk assessment. High risk patients, without contraindications, should be managed more aggressively with coronary angiography. On the other end, low risk patients, and some intermediate, may be evaluated more conservatively with early non-invasive studies for further assessment of ischemia and prognosis.

Diagnosis and management of neoplastic pericardial effusion with cardiac tamponade; review of two case studies at the San Juan Veteran Administration Medical Center

Two case reports of patients with known non-small cell lung cancer that developed cardiac tamponade related to metastatic pericardial disease are described. Both of these patients underwent urgent subxiphoid echocardiographic guided pericardiocentesis. They both were treated with sclerotherapy using intrapericardial bleomycin. There were no complications from these procedures and no recurrence of cardiac tamponade. They both lived more than 6 months after this intervention. This article reviews the pathogenesis, clinical presentation, diagnosis, and current therapeutic interventions of patients with neoplastic pericardial effusion and cardiac tamponade

Early postoperative complications after coronary artery bypass grafting at the San Juan Veterans Affairs Medical Center

OBJECTIVES: Describe the perioperative characteristics of the patients undergoing coronary artery bypass grafting (CABG) in San Juan, Veterans Affairs Medical Center (SJ-VAMC). Determine the in-hospital and 30-day morbidity and mortality following CABG and identify adverse predictors for postoperative complications. BACKGROUND: Preoperative risk factors for complications post-CABG have been identified; however limited data is available regarding the value of these predictors in the Puerto Rican Population. METHODS: Perioperative characteristics and 30-day complications were gathered from all patients undergoing CABG (n = 252) at the SJ-VAMC (2001-2003). Logistic regression analysis was performed to determine factors associated with the occurrence of complications. RESULTS: The population's mean age was 66.9 +/- 8.1 years. Associated illnesses included: hypertension (95.6), diabetes (57), past smoking (61), COPD (26), chronic renal insufficiency (CRI-11.5), cerebrovascular disease (CVD-20.6), disabling angina (78), 3-vessel coronary disease (75.8), significant left main stenosis (20), and non-elective surgical intervention (54). The most frequent primary complications were postoperative myocardial infarction (MI-4.8) and congestive heart failure (4.8). The 30-day mortality was 1.2. Upon multivariate analysis PRBC transfusions > 3 units was associated to increased risks of primary complications, in patients with prior history of CVD. CRI and LVEF < or = 40were independently associated to development of primary complications, in patients with prior MI and CVD. CONCLUSION: The preoperative characteristics are suggestive of an older and sicker patient that is undergoing CABG at the SJ-VAMC. Despite this, the death rate was low and the frequency of other complications comparable to the Society of Thoracic Surgeons (STS) National Adult Cardiac Database.