Faculty Bibliography

Here we present a case of a patient who got trapped in an elevator; on initial evaluation patient was found with bradycardia; on further evaluation electrocardiogram (EKG) showed new onset 2nd-degree Mobitz type 2 AV block. On admission patient developed ischemic changes on EKG and troponin elevation. Transthoracic echocardiogram showed reduced ejection fraction as well as apical inferior, anterior, lateral, and septal hypokinesia. Coronary angiography showed nonobstructive coronary artery disease and ventriculogram demonstrated anterolateral and apical hypokinesia suggesting takotsubo cardiomyopathy (TCM). Atrioventricular block (AV) is rarely seen as initial presentation of TCM and has a prevalence of about 2.9%. AV block during early presentation of TCM poses a therapeutic dilemma with regard to the timing and the need to place a temporary or permanent pacemaker. The decision to place a permanent pacemaker may be on a case-by-case basis and more research is needed on formulating standardized recommendations in patients with TCM and conduction tissue abnormalities.

BACKGROUND: Initial serum potassium (K+) in diabetic ketoacidosis (DKA) often does not reflect the true amount of total body K+ storage, and it is not a good predictor of subsequent hypokalemia. In this study, we tested the hypothesis that a deficiency of the total body K+ storage can be detected initially on surface electrocardiography (ECG). METHOD: Medical records of 350 patients with a diagnosis of DKA were reviewed. Data regarding serial basic metabolic panels, arterial blood gases, serum ketones, and total K+ replacement that patient received during admission were collected. We compared biochemical findings for patients with and without QTU corrected (QTUc) prolongation by using the t test. Patients who were taking medications known to affect QTUc or cause ST-T changes were excluded. RESULTS: After exclusion criteria, 61 patients were enrolled in this study. In 38 patients (62.9%), QTUc was more than or equal to 450 milliseconds. Patients with prolonged QTc received statistically more K+ supplementation during admission (P = .014). They also had lower serum K+ level during their hospital course (P = .002) compared to patients with normal QTUc intervals. No significant difference was found between initial serum K+, calcium, glucose, anion gap, acidosis, age, or heart rate between these 2 groups. CONCLUSION: The significant relationship between K+ depletion and the ECG changes observed in this study deserves further consideration. Our findings confirm the concept that the ECG is an easy and reliable tool for early diagnosis of hypokalemia in patients with DKA.

Presentation of pericardial disease is diverse, with the viral aetiology being the most common cause; however, when haemorrhagic pericardial effusion is present, these causes are narrowed to few aetiologies. We present a case of a young female of African descent who presented with diffuse abdominal pain and vomiting. Initial work-up showed pericardial effusion with impending echocardiographic findings of cardiac tamponade and bilateral pleural effusions. Procedures included a left video-assisted thoracoscopic surgery (VATS) with pericardial window. We consider that it is important for all physicians to be aware of not only typical presentation but also atypical and unusual clinical picture of pericardial disease.

Effectiveness of new oral anticoagulants (NOAC) in patients with cancer is not clearly defined. There remain concerns of doubtful benefit and chances of potential harm with newer agents. In this meta-analysis, we evaluated the efficacy and safety of NOAC in patients with cancer. PubMed, Cochrane Library, EMBASE, Web of Science, and CINAHL databases were searched from January 01, 2001 through February 28, 2013. Randomized controlled trials reporting efficacy and safety data of NOACs (rivaroxaban, dabigatran, and apixaban) with control (low-molecular-weight heparin/vitamin K antagonists/placebo) for patients with cancer were included. Primary efficacy outcome was venous thromboembolism (VTE) or VTE-related death, and primary safety outcome was clinically relevant bleeding. We used random-effects models. Six trials randomized 19,832 patients, and 1197 patients had cancer. Risk of VTE or VTE-related death was not significantly different with NOAC versus control [odds ratio (OR), 0.80; 95% confidence interval (CI), 0.39-1.65] in patients with cancer. Separate analysis for individual effects showed similar results for rivaroxaban (OR, 1.08; 95% CI, 0.60-1.94) and dabigatran (OR, 0.91; 95% CI, 0.21-3.91). Clinically relevant bleeding was not higher with NOAC compared with control (OR, 1.49; 95% CI, 0.82-2.71); individual effect of rivaroxaban showed similar results. No statistically significant difference of efficacy and safety with NOAC was found between patients with and without cancer. Rivaroxaban might be equally effective and safe as vitamin K antagonist in patients with cancer. Dabigatran is as effective as comparator; however, safety profile of dabigatran is unknown. Randomized trials of new anticoagulants specific to the cancer population are necessary, and NOAC also need to be evaluated against low-molecular-weight heparin.

BACKGROUND:The most common symptom of cocaine abuse is chest pain. Cocaine induced chest pain (CICP) shares patho-physiological pathways with the acute coronary syndromes (ACS). A key event is the increase of activity of the adrenergic system. Beta blockers (BBs), a cornerstone in the treatment of ACS, are felt to be contraindicated in the patient with CICP due to a potential of an "unopposed alpha adrenergic effect (UAE)". OBJECTIVES/OBJECTIVE:Identify signs of UAE and in-hospital complications in patients who received BB while having cocaine induced chest pain. METHODS:We performed a retrospective review of 378 patients admitted to a medical unit because of CICP. Twenty six of these were given a BB at the time of admission while having CICP. We compared these patients to a control group paired by age, sex, race and history of hypertension who did not received a BB while having CICP. Blood pressure, heart rate, length of stay and in-hospital cardiovascular complications were compared. RESULTS:No statistically significant differences were found between the two groups except for a longer length of stay in the case group. This was felt to be due to unrelated causes. CONCLUSIONS:This study does not support the presence of an UAE in patients with continuing CICP and treated early with BB. There were no in-hospital cardiovascular complications in the group of patients who had an early dose of BB while having CICP. IMPLICATIONS/CONCLUSIONS:BB appeared safe when given early on admission to patients with CICP.

A 36-year-old Hispanic woman with a history of systemic lupus erythaematosus (SLE) in remission presented with progressive dyspnoea, bilateral leg swelling and increasing fatigue with rapid weight gain over the past few months. Her physical examination showed mildly tender thyromegaly and pericardial rub. Investigations showed new onset marked hypothyroidism as well as an active lupus serology with echocardiogram confirming severe pericardial effusion and a tamponade phenomenon. Urgent pericardiocentesis relieved her acute symptoms, and prompt treatment with thyroxine replacement and immunosuppression for lupus disease was initiated. Pericardial fluid analysis remained negative for any malignancy and/or infection/s. The patient had a gradual and consistent improvement with this treatment. She was discharged and appeared to be clinically stable at subsequent follow-up visits. However, the case remained a diagnostic dilemma over whether the tamponade was being driven by hypothyroidism versus lupus, leaving us with an opportunity to explore further.

Cangrelor is a new parenteral adenosine diphosphate P2Y12 receptor inhibitor with rapid, profound and reversible inhibition of platelet activity. The aim of this meta-analysis was to evaluate efficacy and safety of this new agent in patients undergoing percutaneous coronary intervention (PCI). We searched PubMed, Cochrane Library, EMBASE, Web of Science and CINAHL databases from the inception through April 2013. Randomized controlled trials (RCTs) comparing cangrelor with control (clopidogrel/placebo) were selected. We used the random-effects models to calculate the risk ratio. The primary efficacy outcome was risk of myocardial infarction, and the primary safety outcome was TIMI major bleeding at 48 h. Three RCTs included a total of 25,107 participants. Effects of Cangrelor were not different against comparators for myocardial infarction (MI) (Risk ratio [RR] 0.94, 95 % confidence interval [CI] 0.78-1.13) and all-cause mortality (RR 0.72, 95 % CI 0.36-1.43). However, cangrelor significantly reduced the risk of ischemia-driven revascularization (RR 0.72, 95 % CI 0.52-0.98), stent thrombosis (RR 0.60, 95 % CI 0.44-0.82) and Q wave MI (RR 0.53, 95 % CI 0.30-0.92) without causing extra major bleeding (Thrombolysis in Myocardial infarction criteria) and severe or life-threatening bleeding (Global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries criteria). Separate analysis against only clopidogrel also showed similar findings except Q wave MI outcome. Use of cangrelor during PCI might reduce the risk of ischemia-driven revascularization and stent thrombosis, without causing extra major bleeding.

AIMS: Primary: to determine the safety and efficacy of intravenous sedation for cardiac procedures administered by non-anesthesia personnel. Secondary: to assess cost effectiveness of such sedation. METHODS: Anesthesiologists trained non-anesthesia personnel, and established our sedation protocol, which was then used in 9,558 patients who had cardiac procedures with sedation by non-anesthesia personnel, recorded on a computerized database. Most sedation used was midazolam (MID) and morphine (MOR). Complications and problems were derived from the database and quality assurance committee records. Doses were based on desired level of sedation and procedure duration; highest dose used: MID 78 mg, MOR 84 mg. RESULTS: Data included catheterization (n = 3,819) and transesophageal echo procedures (n = 260); and overall electrophysiology (n = 5,479) and selected subsets. There were complications or problems in only 9 patients (0.1%), a strong safety statement. There were 3 deaths in electrophysiology related procedures, 2 deaths in catheterization related procedures, all in very sick patients and not definitely related to sedation; 4 others developed clinical instability (hives, hypotension and heart failure-all with no sequellae), 2 of which needed reversal medications. Three patients (<0.03%) proved difficult to sedate, and their procedures were completed with help from the anesthesia department; by protocol this was not a complication. A total of $5,365,691 was saved during the last decade on cardiac procedures performed with conscious sedation. CONCLUSION: Non-anesthesia personnel can administer intravenous sedation for cardiac procedures in cardiac settings, with safety and cost-effectiveness demonstrated over many years. Anesthesia services are still appropriate for selected cases.