CCU Conference 8/18/11 MRN 0001171164

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CCU Conference 8/18/11MRN 0001171164

• Naveen Anand Seecheran, M.D.
• FAHC/UVM
• Cardiology F1

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Memorable Cardiology Quotes

• Angioplasties are a little like potato chips.
  You cant have just one!
• -William Castelli, M.D.
• Former Medical Director, F.C.I.
• Franklin BA. Am J Cardiol. 2009 Feb
  1103(3)428-30. Epub 2008 Nov 19. Accessed
  8-16-2011.

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Case Presentation

• PI HPI
• Octogenarian WM
• CP/DOE x 2 days
• Malaise
• MHx SHx
• Remote DVTs/PEs (gt10y ago) ?Coumadin Therapy
• HTN
• HLD
• CKD Stage II-III

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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

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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 BSve
• 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) 45764. doi10.1016/0002-9149(67)
  90023-9. PMID 6059183. Accessed 8-16-2011.

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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.1980303(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. 2004110(5) 588-636.
• GRACE 30 M(IP), 50 M(6mo)

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Case Presentation

• CEs
• Troponin I 0.1
• CK 43
• CXR btl Pl. Effs.
• Hgb 13.7
• WCC 13 (G 60, B 0)
• Cr 2.7
• CrCl 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.

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Case Presentation

• LHC
• LM nl
• LAD 50 mid, 50 D1
• LCFx Small, 80
• RCA 80 PDA
• LVEDP 15
• AVG None
• LVG 70

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STEMI Mimics
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STEMI Mimics
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Clinical Controversy
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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

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Clinical Controversy
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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

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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) 58710. doi10.1016/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)
  10426. doi10.1016/j.jacc.2003.09.055. PMID
  15028364.

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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) 9167. doi10.1016/0002-9149(94)9
  0828-1. 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) 20126. doi10.1161/CIRCULAT
  IONAHA.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) 198791.
  doi10.1001/archinte.165.17.1987. PMID 16186468.
• Steroids
• ? More AEs, recurrences, and hospitalizations

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