Angela DiSabatino

Survival and Neurologic Recovery in Patients With ST-Segment Elevation Myocardial Infarction Resuscitated From Cardiac Arrest

OBJECTIVES We examined outcomes of patients resuscitated from cardiac arrest owing to ST-segment elevation myocardial infarction (STEMI) and predictors of survival and neurologic recovery. BACKGROUND Immediately after resuscitation from cardiac arrest owing to STEMI, many patients show signs of neurologic impairment, and benefits of percutaneous coronary intervention and subsequent prognosis are not well defined. METHODS Between January 1, 2002, and December 31, 2006, we retrospectively identified consecutive patients resuscitated from cardiac arrest, regardless of time to return of spontaneous circulation (ROSC) and neurologic status, and reviewed the outcomes of those who had STEMI. Mortality and neurologic recovery at discharge and long-term mortality were assessed by individual chart review for those who underwent emergent angiography. RESULTS Our study population consisted of 98 patients; 64% survived to discharge, and 92% had a full neurologic recovery. Predictors of survival were shorter time to ROSC, younger age, neurologic status post-resuscitation (alert or minimally responsive), and male sex. Predictors of neurologic recovery included shorter time to ROSC, neurologic status post-resuscitation (alert or minimally responsive), and younger age. Ninety-six percent of patients who were alert post-resuscitation survived. Ninety-three percent of patients who were minimally responsive post-resuscitation survived. Fifty-nine patients were unresponsive post-resuscitation, with 44% survival, of whom 88% had full neurologic recovery. In the unresponsive group, unwitnessed arrest, prolonged ROSC, and older age were associated with increased risk of death, and older age and prolonged ROSC predicted poor neurologic recovery. CONCLUSIONS When resuscitated patients with STEMI are being evaluated in the emergency department, serious consideration should be given to emergent angiography and revascularization, regardless of neurologic status.

Effect of a High Saturated Fat and No-Starch Diet on Serum Lipid Subfractions in Patients With Documented Atherosclerotic Cardiovascular Disease

OBJECTIVE To determine whether a diet of high saturated fat and avoidance of starch (HSF-SA) results in weight loss without adverse effects on serum lipids in obese nondiabetic patients. PATIENTS AND METHODS Twenty-three patients with atherosclerotic cardiovascular disease participated in a prospective 6-week trial at the Christiana Care Medical Center in Newark, Del, between August 2000 and September 2001. All patients were obese (mean +/- SD body mass index [BMI], 39.0+/-7.3 kg/m2) and had been treated with statins before entry in the trial. Fifteen obese patients with polycystic ovary syndrome (BMI, 36.1+/-9.7 kg/m2) and 8 obese patients with reactive hypoglycemia (BMI, 46.8+/-10 kg/m2) were monitored during an HSF-SA diet for 24 and 52 weeks, respectively, between 1997 and 2000. RESULTS In patients with atherosclerotic cardiovascular disease, mean +/- SD total body weight (TBW) decreased 5.2%+/-2.5% (P<.001) as did body fat percentage (P=.02). Nuclear magnetic resonance spectroscopic analysis of lipids showed decreases in total triglycerides (P<.001), very low-density lipoprotein (VLDL) triglycerides (P<.001), VLDL size (P<.001), large VLDL concentration (P<.001), and medium VLDL concentration (P<.001). High-density lipoprotein (HDL) and LDL concentrations were unchanged, but HDL size (P=.01) and LDL size (P=.02) increased. Patients with polycystic ovary syndrome lost 14.3%+/-20.3% of TBW (P=.008) and patients with reactive hypoglycemia lost 19.9%+/-8.7% of TBW (P<.001) at 24 and 52 weeks, respectively, without adverse effects on serum lipids. CONCLUSION An HSF-SA diet results in weight loss after 6 weeks without adverse effects on serum lipid levels verified by nuclear magnetic resonance, and further weight loss with a lipid-neutral effect may persist for up to 52 weeks.

Patients with left main coronary artery vasospasm inadvertently undergoing coronary artery bypass grafting surgery.

To the Editor: Left main coronary artery (LMCA) vasospasm induced by angiographic catheters during coronary angiography, although uncommon, is a recognized complication of this procedure ([1,2][1]). However, the inability to distinguish vasospasm from obstructive disease of the LMCA can lead to

Frequency of Severe Valvular Disease Caused by Mediastinal Radiation Among Patients Undergoing Valve Surgery in a Community-Based, Regional Academic Medical Center

Our goal was to define the prevalence of radiation‐induced valvular heart (RIVD) disease among patients undergoing cardiac valve surgery in a community‐based, regional academic medical center. Mediastinal radiation is a treatment modality for various hematologic and solid malignancies; however, long‐term cardiac complications, including radiation‐induced valvular heart disease, can occur years after the radiation treatments.

ENHANCED BIOACTIVE TGF- LEVELS IN THE MYOCARDIUM SUGGESTS EARLY PATHOLOGICAL TRANSITION IN ASYMPTOMATIC SEVERE MITRAL REGURGITATION

The optimal timing of surgery for asymptomatic severe mitral regurgitation (MR) remains debatable. Excessive TGF-b activation is known to lead to pathological remodeling of the ventricular myocardium. Myocardial tissue and blood samples were collected from patients with severe MR undergoing mitral

PREVALENCE AND OUTCOMES OF ACUTE STEMI PATIENTS WHO WERE ON CHRONIC VITAMIN K ANTAGONIST THERAPY AT THE TIME OF PRESENTATION

Prevalence and outcomes of patients who are on chronic Vitamin K antagonist therapy (VKA) in acute STEMI populations are largely unknown as they were excluded from prospective clinical trials. It is unclear whether chronic VKA is associated with increased longterm mortality. In a large academic

Higher 30-day readmission rate for suspicion of ACS : effect of kidney function

Current evidence suggests prolonged hospitalization for Acute Coronary Syndrome (ACS) in the setting of chronic kidney disease (CKD). What remains unclear is the impact of CKD on 30-day readmission rate for suspected ACS. All patients who came to the emergency department (ED) from 2004 to 2010 and

ELIMINATING CREATININE KINASE-MB (CKMB) IN RULING OUT ACUTE MYOCARDIAL INFARCTION (MI) WHEN TROPONIN (TN) IS AVAILABLE CAN LEAD TO SAVING HUNDREDS OF MILLIONS OF HEALTHCARE DOLLARS

According to the Joint ESC/ACC/AHA/WHF Task Force, Tn is the preferred biomarker for the diagnosis of acute MI. However, it is still common practice to order both serial CKMB and Tn to rule out acute MI. Our hypothesis is that most clinicians only use Tn and not CKMB in further management decisions

THEINFLUENCE OFTIME OFDAY ANDDAY OFWEEK ON THEURGENCY OFNEED FORPREHOSPITALIDENTIFICATION OFPATIENTS WITHACUTEMYOCARDIALINFARCTION

Objective: Ambulance diversion is a major issue countrywide. As patients do not get to requested facilities, challenges in care are compounded by lack of available medical records and delays in transferring admitted patients back to the originally requested facility. Additionally, in an area with high managed care penetration, patient repatriation is important for continuity of care and payment. We hypothesized that if all hospitals would limit diversion using standardized ‘‘rules’’ and accept patient requests, diversion hours would decreased and more patient requests could be honored. Methods: Prospective study in a county of 2.8 million (urban, suburban, rural, remote) involving 150,000 91-1 transports annually to 21 emergency departments (EDs). A community oversight committee was established and two ‘‘rules’’ for diversion were created. 1) An ED can be on diversion for only 1 hour at a time. Diversion could be reestablished only after coming off diversion, still meeting diversion criteria, and accepting one additional ambulance patient. 2) All EDs will accept their own requested ambulance patients, even if on diversion, unless there is a significant safety issue. Data for 12 months prior to the trial were compared with the 11-month post intervention period, except for interfacility transfers (IFTs) in which 2 months pre and post were evaluated. Results: Despite an increase in ambulance runs during the trial period compared with the baseline data (9,958 vs. 9,623, p, 0.05), there was a significant decrease in diversion hours (4,007 vs. 1,560, p value, 0.001) and the number of patients who did not get to the requested facility for diversion issues (1,320 vs. 414, p value , 0.05). The monthly average of IFTs were 1,148 pre vs. 973 post (p, 0.05). Monthly average IFTs for level of care was 429 pre vs. 425 post (p.0.10), for payer request were 619 pre vs. 478 post (p, 0.05), and for payer request that arrived via ambulance were 317 pre vs. 217 post (p, 0.05). Conclusion: A voluntary community-wide approach to attempt to get ambulance patients to requested facilities and decrease ambulance diversion can be effective and has the effect of decreasing the number of ED interfacility transfers. 13 ASSOCIATION OF OUT-OF-HOSPITAL ENDOTRACHEAL INTUBATION