CCU Conference
8/18/11
MRN# 0001171164
Naveen Anand Seecheran, M.D.
FAHC/UVM
Cardiology F1
Memorable Cardiology Quotes
• “Angioplasties are a little like potato chips.
You can’t have just one!”
-William Castelli, M.D.
Former Medical Director, F.C.I.
Franklin BA. Am J Cardiol. 2009 Feb 1;103(3):428-30. Epub 2008 Nov 19. Accessed: 8-16-2011.
Case Presentation
• PI & HPI
Octogenarian WM
– CP/DOE x 2 days
– Malaise
• MHx & SHx
–
–
–
–
Remote DVTs/PEs (>10y ago) ?Coumadin Therapy
HTN
HLD
CKD Stage II-III
Case Presentation
• SoHx
–
–
–
–
–
Occasional etOH, lifelong non-smoker
Widower, (wife died few months earlier)
No PCP
No Cardiologist
No Insurance
• FHx
– No premature CAD & SCD
• MedHx
– Warfarin 5mg
– Metoprolol Tartrate 25mg q12h
– Simvastatin 40 mg
Case Presentation
• PE:
– VS
• BP 130s/80s, P 100s, RR 20s, spO2 97% 3L NC
– AAOX3, GCS 15
– S1 S2 O M/R/G/H/CB/5cm JVD
– Bibasilar Crackles
– S/NT/ND 0 M BS+ve
– 0 CNS Deficit
– Pulses ++ btl 0 C/E/C
–
Killip T, Kimball JT (Oct 1967). "Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients". Am J Cardiol. 20 (4): 457–
64. doi:10.1016/0002-9149(67)90023-9. PMID 6059183. Accessed 8-16-2011.
Case Presentation
• Assessment
• ACS-STEMI
•
•
DeWood MA, Spores J, Notske R, et al. Prevalence of total coronary occlusion during the early hours of transmural myocardial
infarction. N Engl J Med.1980;303(16):897-902.
Antman EM, Anbe DT, Armstrong PW, et al. ACC/ AHA guidelines for the management of patients with ST-elevation myocardial
infarction: executive summary: a report of the American College of Cardiology/ American Heart Association Task Force on Practice
Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction).
Circulation. 2004;110(5): 588-636.
• GRACE 30% M(IP), 50% M(6mo)
Case Presentation
• CEs:
– Troponin I
– CK
•
•
•
•
•
•
CXR:
Hgb:
WCC:
Cr:
CrCl:
0.1
43
btl Pl. Effs.
13.7
13 (G 60%, B 0%)
2.7
23
Levey AS, Greene T, Kusek JW, et al. A simplified equation to predict glomerular filtration rate from serum creatinine (Abstr) J Am Soc Nephrol
2000;(11):155A Accessed 8-16-2011.
Case Presentation
• LHC:
– LM:
– LAD:
– LCFx:
– RCA:
– LVEDP:
– AVG:
– LVG:
nl
50% mid, 50% D1
Small, 80%
80% PDA
15
None
70%
STEMI Mimics
STEMI Mimics
Clinical Controversy
Clinical Controversy
•
Results:
–
–
•
2213 activations during 12/08-05/09
18% were canceled prior to catheterization
Cancelation:
–
–
–
–
–
ECG Re-interpretation 9%
Not a cath. candidate 4%
Expired 1%
CP/ST resolution 2%
Other 4%
•
88% were found to have an acute coronary artery occlusion
•
Conclusions:
–
–
–
Low cancelation rate
Systematic cath. laboratory activation by emergency personnel is feasible and accurate
Standard for STEMI system performance
Clinical Controversy
Clinical Controversy
• Results:
–
–
–
–
–
1335 patients with suspected STEMI underwent angiography
14% (CI 12.2%-16.0%) had no culprit coronary artery
9.5% (CI 8.0%-11.2%) did not have significant CAD
Cardiac biomarker levels were negative in 11.2% (CI 9.6%- 13.0%)
Combination of no culprit artery with negative cardiac biomarker present
in 9.2% (CI 7.7%-10.9%)
• Conclusions:
– Frequency of false-positive cardiac catheterization laboratory activation
for suspected STEMI is relatively common in community practice,
depending on the definition of false-positive
– Recent emphasis on rapid D2B times must also consider the
consequences of false-positive catheterization laboratory activation
Acute Pericarditis
• NSAIDs
– Ibuprofen
• Preferred AE Profile
• Improved CBF
•
Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH (2004). "Guidelines on the diagnosis and
management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European
Society of Cardiology". Eur Heart J 25 (7): 587–10. doi:10.1016/j.ehj.2004.02.002. PMID 15120056.
– ASA
–
Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R (2004). "Day-hospital treatment of acute pericarditis: a
management program for outpatient therapy". J Am Coll Cardiol 43 (6): 1042–6. doi:10.1016/j.jacc.2003.09.055. PMID 15028364.
Recurrent Pericarditis
• Colchicine (Recurrence)
–
–
–
Adler Y, Zandman-Goddard G, Ravid M, Avidan B, Zemer D, Ehrenfeld M, Shemesh J, Tomer Y, Shoenfeld Y (1994). "Usefulness of colchicine in preventing
recurrences of pericarditis". Am J of Cardiol 73 (12): 916–7. doi:10.1016/0002-9149(94)90828-1. PMID 8184826.
Imazio M, Bobbio M, Cecchi E, Demarie D, Demichelis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghisio A, Belli R, Trinchero R (2005). "Colchicine in
addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial". Circulation 112 (13): 2012–6.
doi:10.1161/CIRCULATIONAHA.105.542738. PMID 16186437.
Imazio M, Bobbio M, Cecchi E, Demarie D, Pomari F, Moratti M, Ghisio A, Belli R, Trinchero R (2005). "Colchicine as first-choice therapy for recurrent pericarditis:
results of the CORE (COlchicine for REcurrent pericarditis) trial". Arch Intern Med 165 (17): 1987–91. doi:10.1001/archinte.165.17.1987. PMID 16186468.
• Steroids
– ? More AEs, recurrences, and hospitalizations