Subject(s)
Echocardiography, Doppler, Color , Electrodes, Implanted/adverse effects , Heart Block/therapy , Pacemaker, Artificial/adverse effects , Postoperative Complications/etiology , Tricuspid Valve Insufficiency/etiology , Aged , Aortic Valve/surgery , Aortic Valve Stenosis/etiology , Aortic Valve Stenosis/surgery , Atrial Flutter/complications , Atrial Flutter/surgery , Bioprosthesis , Catheter Ablation , Ehlers-Danlos Syndrome/complications , Heart Block/complications , Heart Valve Prosthesis , Humans , Male , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/etiology , Tricuspid Valve Insufficiency/diagnostic imagingABSTRACT
The assessment of quality in the cardiac catheterization laboratory is a complex, ongoing process that requires a comprehensive analysis of the multiple elements of quality. Although clinical outcomes are a reflection of the quality process, they derive from a complex interaction of clinical, technical, and process-of-care components. Procedural volume is associated but not equated with clinical outcomes, although the magnitude of this association depends on numerous covariates, most notably the diminishing rate of adverse outcomes over time.
Subject(s)
Cardiac Catheterization , Outcome Assessment, Health Care , Quality of Health Care , Total Quality Management , Clinical Competence , Coronary Disease/therapy , Humans , Myocardial Infarction/therapy , WorkloadABSTRACT
A 28-year-old, moderately obese man with dyslipidemia (low-density lipoprotein 163 mg/dL, high-density lipoprotein 33 mg/dL), hypertension, active tobacco use (1 pack per day), and a family history for premature coronary artery disease (CAD) initially presented with burning, nonexertional chest discomfort exacerbated by deep inspiration. His initial electrocardiogram (ECG; Fig. 1A) was interpreted as pericarditis because of the diffuse mild ST-segment elevation and PR-segment depression. An echocardiogram demonstrated normal left ventricular systolic function and a trivial pericardial effusion. He was treated with nonsteroidal antiinflammatories and his symptoms resolved. Follow-up ECG performed the next morning (Fig. 1B) demonstrated sinus rhythm, persistent mild ST elevation, and biphasic T waves in leads V3-V4 as well as in leads III and aVF. Four months later, the patient returned with similar symptoms of chest discomfort and was admitted with the diagnosis of unstable angina. The admission ECG was unremarkable showing no persistent PR or ST-T abnormalities. He was ruled out for myocardial infarction by serial enzymes. An exercise myocardial perfusion imaging study was obtained. The patient exercised for 7 minutes 33 seconds on a standard Bruce protocol, obtained 9.4 METs, and reached 69% of maximum predicted heart rate. His exercise ECG revealed up to 2.5 mm of ST-segment elevation in leads V3-V5 accompanied by chest discomfort. The patient's chest pain resolved with cessation of exercise and 1 sublingual nitroglycerin. The ECG returned to baseline within 3 minutes of recovery. He was referred for coronary angiography and was found to have a proximal left anterior descending (LAD) stenosis and underwent percutaneous coronary intervention with stenting. He was discharged home on postprocedure day 3.
