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ST-segment elevation in aVR has traditionally been used for electrocardiographic identification of left main coronary artery (LM) myocardial infarction. We present two ST-segment elevation myocardial infarction (STEMI) cases with acute total occlusion of the LM without aVR ST-segment elevation. This report reviews the different electrocardiographic discriminators suggestive of unprotected LM STEMI. (Level of Difficulty: Intermediate.).
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OBJECTIVE: To evaluate the appropriate clinical use of an acute rest myocardial perfusion imaging (R-MPI) in the initial emergency department (ED) evaluation of a patient presenting with chest pain (CP). METHODS: This is a retrospective study of patients evaluated with CP at the ED with an acute R-MPI. The data collected included medical history, clinical presentation, electrocardiogram, laboratory data, MPI results, confirmatory studies, disposition diagnosis and cost analysis. RESULTS: Three-hundred-sixty-six (366) patients were evaluated. The population studied had a mean Thrombolysis in Myocardial Infarction (TIMI) score of 2 and predominance of patients in the Virginia Commonwealth University (VCU) CP Category-Scale between level 3 and 4 (34% and 49% respectively). The risk of acute coronary syndrome (ACS) was significantly higher in patients with abnormal compared to normal studies (50% versus 0.4%; P < .0005; RR, 129.5; 95% CI, 18 to 924). There were a total of 14 and 19 major adverse cardiovascular events (MACE) events during the follow-up of 30-days and 1-year respectively. There were no cardiovascular fatalities. The risk of MACE at 30-days was significantly higher in patients with abnormal compared to normal studies (12% versus 0.4%; P < .001; RR, 32; 95% CI, 4.2 to 240), as well as with 1-year of follow-up (14% versus 1.6%; P < .001; RR, 9.1; 95% CI, 3.1 to 27). CONCLUSION: Using acute R-MPI in the evaluation of non-high risk patients presenting with CP is a safe, reliable and cost-effective strategy to be used in the ED to predict ACS and future MACE.
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Síndrome Coronariana Aguda/diagnóstico , Dor no Peito/etiologia , Imagem de Perfusão do Miocárdio/métodos , Síndrome Coronariana Aguda/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência , Feminino , Seguimentos , Hospitais de Veteranos , Humanos , Masculino , Pessoa de Meia-Idade , Porto Rico/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos , United States Department of Veterans Affairs , Adulto JovemRESUMO
After presenting to the emergency department with severe chest pain, this patient was thought to be experiencing acute myocardial infarction until imaging tests revealed apical ballooning syndrome.
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BACKGROUND: Patients that present with acute STEMI have proven morbidity and mortality benefit from early reperfusion therapy. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend either fibrinolytic therapy within 30 minutes or a primary percutaneous coronary intervention (PPCI) within 90 minutes of patients arrival to the Emergency Department. Despite these recommendations, some patients do not receive reperfusion therapy and less than half receive it on time. OBJECTIVES: Describe and analyze our reperfusion therapy performance in patients presenting with acute ST segment elevation myocardial infarct (STEMI) in the Veteran Administration Caribbean Healthcare System (VACHS), and determine potential causes for reperfusion therapy delays and develop strategies and a tailored algorithm according to our clinical findings and available institutional resources. METHODS: Retrospective analysis of patients admitted to the VACHS with a discharge diagnosis of STEMI, from 01/01/2007 until 04/10/2008. RESULTS: A total of 55 patients met inclusion criteria for STEMI diagnosis. Of these, only 30 patients had active indication for reperfusion therapy. Reperfusion therapy was given in 97% of the cases, 69% with PPCI and 31% with fibrinolytic therapy (tenecteplase). In general the selection of reperfusion therapy seemed adherent to ACC/AHA STEMI guidelines. The reperfusion time goal was superior with thrombolytic therapy compared to PPCI, with 43% and 15% respectively. PPCI performed off regular tour of duty was significantly delayed compared to regular day shift, with a mean time of 221 and 113 minutes respectively (p=0.027). CONCLUSIONS: Most of the patients presenting with STEMI to the VACHS undergo reperfusion therapy. PPCI was the most frequent selected reperfusion approach. The PPCI time goal was infrequently met. The most significant cause for PPCI delay was related to performance off regular tour of duty. These finding support the implementation of a tailored STEMI reperfusion algorithm favoring timely reperfusion.
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Angioplastia Coronária com Balão , Infarto do Miocárdio/terapia , Terapia Trombolítica , Idoso , Algoritmos , Contraindicações , Angiografia Coronária , Eletrocardiografia , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/diagnóstico por imagem , Reperfusão Miocárdica , Porto Rico , Estudos Retrospectivos , Tenecteplase , Fatores de Tempo , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento , Estados Unidos , United States Department of Veterans AffairsRESUMO
We report the cases of 2 patients who presented with clinical and echocardiographic evidence of cardiac tamponade. Therapeutic echocardiographic-guided pericardiocentesis yielded bloody fluid. In both patients, Definity perflutren lipid microspheres were used for echocardiographic contrast, which helped to assess the needle's location. To the best of our knowledge, this is the 1st reported use of perflutren microspheres for this purpose.
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Tamponamento Cardíaco/diagnóstico por imagem , Meios de Contraste , Microesferas , Pericardiocentese , Idoso , Idoso de 80 Anos ou mais , Fluorocarbonos , Hematócrito , Humanos , Masculino , Pericardite/diagnóstico por imagem , Recidiva , UltrassonografiaRESUMO
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.
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Adenocarcinoma/complicações , Carcinoma Pulmonar de Células não Pequenas/complicações , Tamponamento Cardíaco/etiologia , Neoplasias Pulmonares/complicações , Derrame Pericárdico/etiologia , Derrame Pericárdico/terapia , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/mortalidade , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Broncoscopia , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Carcinoma Pulmonar de Células não Pequenas/patologia , Tamponamento Cardíaco/diagnóstico , Progressão da Doença , Drenagem , Ecocardiografia , Eletrocardiografia , Seguimentos , Humanos , Pulmão/patologia , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Derrame Pericárdico/diagnóstico , Derrame Pericárdico/diagnóstico por imagem , Derrame Pericárdico/cirurgia , Pericardiectomia , Pericardiocentese , Radiografia Torácica , Escleroterapia , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
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 = 40% were 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.
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Ponte de Artéria Coronária/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Ponte de Artéria Coronária/estatística & dados numéricos , Doença das Coronárias/epidemiologia , Doença das Coronárias/cirurgia , Hospitais de Veteranos/estatística & dados numéricos , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Porto Rico/epidemiologia , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
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.