Discharge timing and outcomes after uncomplicated non-ST-segment elevation acute myocardial infarction.

BACKGROUND: Length of stay after non-ST-segment elevation myocardial infarction (NSTEMI) continues to decrease, but information to guide duration of hospitalization is limited. METHODS: We used landmark analyses, in which the landmark defined potential days of discharge, to estimate complication rates on the first day the patient would have been out of the hospital, and estimated associations between timing of discharge and 30-day and 1-year event-free survival after discharge among NSTEMI patients. RESULTS: Among 20,410 NSTEMI patients, median length of stay was 7 (4, 12) days; 3,209 (15.7%) experienced a cardiac complication on days 0 to 2 and 1,322 (6.5%) were discharged without complications during hospital days 0 to 2. At the start of day 3, 15,879 patients (77.8%) were still hospitalized without complications. Of these, 1,689 (10.6%) were discharged event-free on day 3. Adjusted event-free survival rates of death or myocardial infarction from day 4 to 30 days after among the 1,689 patients was 99.1% compared with 93.1% for the 14,190 who remained hospitalized at the end of day 3. For 1-year mortality, these rates were 98.1% and 96.4%, respectively. Among 13,334 patients hospitalized without complications at the start of day 4, 1,706 were discharged event-free that day. Adjusted survival rates among these patients, compared with those still hospitalized at the end of day 4, were 98.0% versus 93.7% for 30-day death or myocardial infarction and 97.8% versus 96.1% for 1-year mortality. CONCLUSIONS: Patients with NSTEMI who had no serious complications during the first 2 hospital days were at low risk of subsequent short- and intermediate-term death or ischemic events.

Sinus arrest following angioplasty and stenting for superior vena cava syndrome.

Superior vena cava (SVC) syndrome is a complication resulting from long-term residence of leads or in-dwelling catheters at the SVC to right atrial (RA) junction. SVC syndrome management is complicated by variable responses to anticoagulation therapies and technically challenging interventional procedures, such as balloon dilatation or stent placement at the SVC-RA junction to relieve blood-flow obstruction. Potential complications resulting from angioplasty/stenting for SVC syndrome are serious and include stent migration, major bleeding, and embolism. Bradyarrhythmias have not been reported. We describe a case of balloon angioplasty and stenting for SVC syndrome in a dialysis patient that resulted in sinus arrest. The complication developed within hours of angioplasty/stenting of her chronic, non-thrombotic SVC obstruction. We highlight the management approach to this patient and discuss potential mechanisms underlying the complication.

Mechanical circulatory support for right ventricular failure.

OBJECTIVES: The aim of this study was to explore the clinical utility of a commercially available centrifugal flow pump as a centrifugal flow-right ventricular support device (CF-RVSD) in patients with right ventricular failure (RVF). BACKGROUND: RVF is associated with high in-hospital mortality. Limited data regarding efficacy of the CF-RVSD for RVF exist. METHODS: We retrospectively reviewed data from 46 patients receiving a CF-RVSD for RVF from a registry comprising data from 8 tertiary-care hospitals in the United States. CF-RVSD use was recorded in the setting of acute myocardial infarction; myocarditis; chronic left heart failure; after valve surgery, orthotopic heart transplantation, left ventricular assist device surgery, coronary bypass grafting. Devices were implanted via the percutaneous (n = 22) or surgical (n = 24) route. RESULTS: No intraprocedural mortality was observed. Mean time from admission to CF-RVSD implantation was 5.7 ± 8.5 days, with a mean of 6,769 ± 789 rotations/min, providing 4.2 ± 1.3 l/min of flow. Mean duration of support was 5.4 ± 5.1 days. Mean arterial pressure (65 ± 12 mm Hg vs. 73 ± 14 mm Hg; p < 0.05), right atrial pressure (21 ± 8 mm Hg vs. 16 ± 7 mm Hg; p = 0.05), pulmonary artery systolic pressure (43 ± 15 mm Hg vs. 33 ± 15 mm Hg; p = 0.01), and cardiac index (1.7 ± 0.7 vs. 2.2 ± 0.6; p = 0.01) were improved within 48 h of CF-RVSD implantation. Total in-hospital mortality was 57% and was lowest in the setting of left ventricular assist device implantation, chronic left heart failure, and acute myocardial infarction. Increased age, biventricular failure, and Thrombolysis In Myocardial Infarction-defined major bleeding were associated with increased in-hospital mortality. CONCLUSIONS: Use of the CF-RVSD for RVF is clinically feasible and associated with improved hemodynamic status. Observations from the registry of patients who have received this device may support the development of prospective studies that will examine the role of percutaneous circulatory support for RVF.

Emphasizing statin safety in the hospitalized patient: a review.

This review examines the safe use of statin therapy in the hospitalized patient. Available data support initiation of statin therapy during hospitalization in patients with acute coronary syndromes or established cardiovascular disease and in high-risk patients with diabetes mellitus and chronic kidney disease (except for those on maintenance hemodialysis). Because of the increased risk of cardiovascular disease, statins are given to solid-organ transplant survivors and those treated with protease inhibitors for human immunodeficiency virus. However, in the multidrug, acute illness hospital environment, safety considerations become paramount. We review the essentials of statin metabolism and drug-drug interactions to provide the hospital physician with information to minimize potentially serious adverse statin effects.

Eptifibatide-induced thrombocytopenia: with thrombosis and disseminated intravascular coagulation immediately after left main coronary artery percutaneous coronary angioplasty.

Early clinical trials of eptifibatide did not show a significant association between eptifibatide and the development of thrombocytopenia, thrombosis, or disseminated intravascular coagulation. However, more recent literature has suggested a significant association between eptifibatide and the development of thrombocytopenia and thrombosis. Although the true incidence and the pathophysiology of these associations are unknown, the development of these events can be life-threatening. Herein, we describe the case of a patient who experienced acute onset of profound thrombocytopenia, developing thrombosis, pulmonary emboli, and disseminated intravascular coagulation. This paper adds to the few previous reports of cases that suggested an association between thrombocytopenia, thrombosis, and the administration of eptifibatide. To the best of our knowledge, this is the first case report in the medical literature that associates the new onset of thrombocytopenia, thrombosis, and disseminated intravascular coagulation with the administration of eptifibatide. We also provide a subject review.

Clinical experience and patient outcomes associated with the TandemHeart percutaneous transseptal assist device among a heterogeneous patient population.

There is a paucity of literature describing the outcomes associated with the use of TandemHeart percutaneous ventricular assist device (PVAD). The literature is limited by analyzing only subsets of patients. We present the clinical outcomes and safety associated with the use of TandemHeart among a series of heterogeneous patients requiring PVAD support. We reviewed the clinical experience, hemodynamic variables, survival outcomes, and complications associated with the implantation of TandemHeart support device among 25 patients presenting to our institution. Indications for PVAD implantation were cardiogenic shock (56%), ST-segment elevation myocardial infarction (STEMI) (20%), postpericardiotomy (16%), and high-risk percutaneous coronary interventions (PCI) or ventricular tachycardia (VT) ablation (8%). TandemHeart was used for an average of 4.8 ± 2.1 days and demonstrated significant hemodynamic improvements (pre- and postimplantation left ventricular ejection fractions were 21.5% ± 15% and 24.5% ± 10.5%, respectively [p = 0.06]). The cardiac index improved from a mean 2.04 ± 075 L/min/m² to 2.45 ± 073 L/min/m² (p = 0.09). The mixed venous oxygen saturation (SVO2) increased from 55.14 ± 13.34 to 66.43 ± 7.43 (p = 0.008) after implantation. TandemHeart was used as a bridge to left ventricular assist device implantation (44%) or recovery (20%). Thirty-six percent of patients died on support or shortly after PVAD removal. Thirty, 90-day, and long-term (>90 days) survival rates were 56%, 52%, and 36%, respectively. Procedure-related complications were reported in 13 patients (56%), and the majority (90%) was related to vascular access (bleeding or pseudoaneurysm). The TandemHeart device is a safe therapeutic option as a bridge-to-recovery or bridge-to-bridge for patients with hemodynamic compromise regardless of the etiology. The favorable hemodynamic profile, postimplantation survival rates, and manageable complications support its use to assist hemodynamic recovery in patients refractory to conventional therapy.

Leveraging time and learning style, iPod vs. realtime attendance at a series of medicine residents conferences: a randomised controlled trial.

OBJECTIVE: To determine whether participation in educational conferences utilising iPod technology enhances both medical knowledge and accessibility to educational content among medical residents in training. DESIGN/MEASUREMENTS: In May 2007, the authors led a randomised controlled study involving 30 internal medicine residents who volunteered either to attend five midday educational conferences or to use an iPod audio/video recording of the same conferences, each followed by a five-question competency quiz. Primary outcomes included quantitative assessment of knowledge acquisition and qualitative assessment of resident perception of ease of use. Secondary outcomes included resident perception of self-directed learning. RESULTS: At baseline, residents reported attendance at 50% of educational conferences. Of iPod participants, 46.7% previously used an iPod. During the study, 46-60% of conference attendees were paged out of each conference, of whom between 6 and 33% missed more than half of the conference. The quiz completion rate was 93%. Key findings were: 1) similar quiz scores were achieved by conference attendees, mean 60.7% (95% CI; 53.0-68.3%), compared to the iPod user group, mean 67.6% (95% CI; 61%-74.1%), and 2) the majority (10/15, 66.6%) of conference attendees stated they would probably benefit from the option to refer back to conferences for content review and educational purposes. CONCLUSIONS: Residency training programmes can optimise time management strategies with the integration of innovative learning resources into educational curricula. This study suggests that iPod capture of conferences is a reasonable resource to help meet the educational goals of residents and residency programs.

Personal digital assistants: a review of current and potential utilization among medical residents.

BACKGROUND: Increases in the daily work load of medical residents, coupled with constraints on their work hours have made personal digital assistants (PDAs) an increasingly popular management resource. No comprehensive review of PDA utilization among medical residents has been published. PURPOSE: The purpose is to review and analyze current literature addressing PDA use by medical residents and to asses the future impact handheld computers may have on the daily practices of residents. METHOD: A systematic literature search was completed to identify publications that describe the use of PDAs by medical residents. Particular attention and priority was given to articles addressing patient care, information management, and educational outcomes. RESULTS: The rate of PDA utilization has dramatically increased in the past decade. Today, 70% of residents report using a PDA daily. PDAs are most commonly used for referencing medication-prescribing guides, medical textbooks, patient documentation programs, and medical calculators. No articles have reported the impact of housestaff PDA use on educational or patient care outcomes. CONCLUSION: PDAs are perceived as a valuable resource by most medical residents. Further studies are necessary to confirm that daily PDA use by housestaff confers an educational, institutional, and patient care benefit.

An interesting case of positional hypoxia: the effect of multiple synergistic pathological conditions.

This report describes an elderly patient evaluated for generalized fatigue, dyspnea, presyncopal episodes, and positional hypoxemia. Workup revealed posturally related oxygen desaturation, a patent foramen ovale (PFO), an atrial septal aneurysm, and primary adrenal insufficiency. Normal intracardiac pressures and a right-to-left PFO shunt were present only while the patient was in the upright position. Numerous etiologies of positional right-to-left shunting associated with platypnea-orthodeoxia have been described. Despite advancements in diagnostic and treatment modalities, the pathophysiology of right-to-left shunting with normal intracardiac pressure remains elusive. This report highlights the complexity of positional right-to-left shunting in hypoxemic patients with normal intracardiac pressures and multiple synergistic medical conditions.

Platelet inhibitors: what are the data in women?

Cardiovascular disease is the leading cause of disability and mortality among women in the United States. However, relative to their representation among the overall population of patients presenting with acute coronary syndromes, women have been underrepresented in clinical trials of treatment strategies for acute coronary syndromes. In general, subgroup analyses and meta-analyses of the data from the major treatment trials have demonstrated similar treatment effects among women and men, but questions recently have been raised regarding the role and effect of antiplatelet therapy in the treatment of women. This article will review the use of antiplatelet therapy in women from the perspective of both primary and secondary prevention using as a focus for discussion recent randomized clinical trial data and registry observations of the potential benefits and risks of antiplatelet therapy in women.

The influence of low (81 mg) versus high (325 mg) doses of ASA on the incidence of sirolimus-eluting stent thrombosis.

BACKGROUND: Conflicting opinion exists regarding the optimal dose of acetyl salicylic acid (ASA) to be given after percutaneous coronary intervention (PCI) with drug-eluting stents (DES). We sought to evaluate the influence of ASA dose on the incidence of unexplained subacute and late stent thrombosis in the era of DES. METHODS: We performed a retrospective analysis of the incidence of subacute and late stent thrombosis in our patient population over a 2-year period. The analysis was limited to patients being discharged and maintained on a daily ASA dose of either 81 mg or 325 mg and having received at least 1 sirolimus-eluting stent. RESULTS: During the study period, 1,093 patients (1,807 separate PCI procedures) met the inclusion criteria. The incidence of unexplained subacute and late stent thrombosis was 1.1% in the study population (12 out of 1,093 patients). When considering the total number of individual procedures performed on the study population during the study period (1,807 procedures), the incidence of unexplained subacute or late stent thrombosis was 0.7%. Six were subacute and 6 were late thrombosis. No significant difference was observed in the incidence of stent thrombosis between the 2 ASA dose groups. Seven patients had stent thrombosis in the 81 mg group (1.2% of 583 patients), while 5 had thrombosis in the 325 mg group (1% of 510 patients); p = 0.727. CONCLUSION: In conclusion, we found no significant difference in the incidence of unexplained subacute or late stent thrombosis with the use of an 81 mg versus 325 mg dose of aspirin post-PCI with sirolimus-eluting stents.