Absorbable Suture Embolization in Distal Coronary Perforation.

Coronary artery perforation is a rare but serious complication during percutaneous coronary intervention. Distal or small vessel perforation is usually treated by coil, fat, or microsphere embolization. We describe 5 cases of distal coronary perforation that were managed successfully by a novel technique that uses absorbable sutures. (Level of Difficulty: Advanced.).

Development of salient medication reminders to facilitate information transfer during transition from inpatient to primary care: the Delphi process.

OBJECTIVE: Transitional care is important to successful hospital discharge. Providing patients with a clear and concise summary of medication-related information can help improve outcomes, in particular, among older adults. The present study aimed to propose a framework for the development of salient medication reminders (SMR), which include drug-related risks and precautions, using the Delphi process. DESIGN: Identification of potential SMR statements for 80% of medication types used by older adult patients discharged from geriatric medicine departments, followed by a Delphi survey and expert panel discussion. SETTINGS: Medical and geriatric departments of public hospitals in Hong Kong. PARTICIPANTS: A panel of 13 geriatric medical experts. OUTCOME MEASURE: A Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) points, scoring item relevance, importance and clarity. The minimum of 70% consensus was required for each statement to be included. RESULTS: The expert panel achieved consensus through the Delphi process on 80 statements for 44 medication entities. Subsequently, the SMR steering group endorsed the inclusion of these statements in the SMR to be disseminated among older adults at the time of discharge from geriatric medicine departments. CONCLUSIONS: The Delphi process contributed to the development of SMR for older adult patients discharged from public hospitals in Hong Kong. Patient experience with and staff response to the SMR were assessed at four hospitals before implementation at all public hospitals.

Prognosticating Clinical Prediction Scores Without Clinical Gestalt for Patients With Chest Pain in the Emergency Department.

BACKGROUND: Assessment of patients with chest pain is a regular challenge in the emergency department (ED). Recent guidelines recommended quantitative assessment of ischemic risk by means of risk scores. OBJECTIVE: Our aim was to assess the performance of Thrombosis in Myocardial Infarction (TIMI); Global Registry of Acute Coronary Events (GRACE); history, electrocardiogram, age, risk factors, and troponin (HEART) scores; and the North America Chest Pain Rule (NACPR) without components of clinical gestalt in predicting 30-day major adverse cardiac events (MACE). METHODS: We performed a prospective cohort study in adult patients who attended the ED with undifferentiated chest pain. Clinical prediction rules were applied and calculated. The clinical prediction rules were modified from the original ones, excluding components requiring judgment by clinical gestalt. The primary outcome was MACE. Performance of the tests were evaluated by receive operating characteristic curves and the area under curves (AUC). RESULTS: There were 1081 patients included in the study. Thirty-day MACE occurred in 164 (15.2%) patients. The AUC of the GRACE score was 0.756, which was inferior to the TIMI score (AUC 0.809) and the HEART score (AUC 0.845). A TIMI score ≥ 1 had a sensitivity of 97% and a specificity of 45.7%. A GRACE score ≥ 50 had a sensitivity of 99.4% and a specificity of 7.5%. A HEART score ≥ 1 had a sensitivity of 98.8% and a specificity of 11.7%. The NACPR had a sensitivity of 93.3% and a specificity of 51.5%. CONCLUSIONS: Without clinical gestalt, the modified HEART score had the best discriminative capacity in predicting 30-day MACE.

Role of copeptin in dual-cardiac marker strategy for patients with chest pain presented to ED.

OBJECTIVE: The objective of the study is to evaluate the role of copeptin in the diagnosis of acute coronary syndrome (ACS) and its role in dual-cardiac marker diagnostic strategy with troponin. DESIGN: A prospective cohort study was carried out from May 2012 to October 2012. SETTING: The study was conducted at the emergency department (ED) of a public hospital in a cluster of Hong Kong. METHODS: Patients aged at least 18 years presented with chest pain to ED who have intermediate or high likelihood of ACS were included. All patients had blood taken in the ED for copeptin and troponin I. The adjudicated diagnoses of ACS were made by 2 independent physicians based on the universal definition. Diagnostic characteristics were calculated. Receiver operating characteristic curves were created. Areas under the curves were compared for copeptin, troponin I, and dual-marker strategy with copeptin and troponin I. RESULTS: A total of 637 patients were recruited. Seventy-eight had been diagnosed to be ACS. The negative predictive value of copeptin for ACS was 0.881 (0.849-0.907) compared with troponin I, 0.937 (0.913-0.956). The areas under the receiver operating characteristic curves of copeptin, troponin I, and dual-marker strategy were 0.68, 0.859, and 0.880, respectively. CONCLUSIONS: Addition of copeptin to troponin does not have significant improvement of the diagnostic accuracy of ACS in patients presented with chest pain.