Howard S. Rosman

Role of Telemetry Monitoring in the Non-Intensive Care Unit.

To determine the outcomes of patients admitted to a non-intensive care telemetry unit and to assess the role of telemetry for guiding patient management decisions, data from 2,240 patients admitted to a telemetry unit were collected prospectively during 7 months. Physicians recorded the outcomes (intensive care unit transfer and mortality) and assessed whether telemetry assisted in guiding patient management. Indications for admission to the telemetry unit included chest pain syndromes (55%), arrhythmias (14%), heart failure (12%), and syncope (10%). Telemetry led to direct modifications in management in 156 patients (7%; 95% confidence interval [CI] 5.9% to 8%). Telemetry was perceived as useful but did not alter management for 127 patients (5.7%; 95% CI 4.7% to 6.6%). Two hundred forty-one patients were transferred to an intensive care unit from the telemetry unit (10.8%; 95% CI 9.5% to 12%). Nineteen patients (0.8% of all admissions; 95% CI 0.5% to 1.2%) were transferred because of an arrhythmia identified by telemetry. Routine transfer after cardiac revascularization or surgery accounted for 134 transfers; clinical deterioration accounted for 88 transfers. There were 20 deaths in the unit (0.9%; 95% CI 0.5% to 1.3%): 4 of the 20 deaths occurred while patients were being monitored. The role of telemetry in guiding patient management may be overestimated by physicians, since it detected significant arrhythmias that led to change in medications or urgent interventions in a small fraction of patients.

The evolving pattern of digoxin intoxication : observations at a large urban hospital from 1980 to 1988

Digoxin intoxication has been reported to be a common adverse drug reaction with an in-hospital incidence of 6% to 23% and an associated mortality rate as high as 41%. A retrospective review was conducted to assess the accuracy of diagnosis, the morbidity and mortality of digoxin intoxication, and its incidence in hospitalized patients with heart failure. We reviewed the medical records of 219 patients discharged with the diagnosis of digoxin intoxication between 1980 and 1988. Patients were classified as follows: (1) Definite intoxication--patients with symptoms and/or arrhythmias suggestive of digoxin intoxication that resolved after discontinuation of digoxin; (2) possible intoxication--patients with symptoms and/or arrhythmias suggestive of digoxin intoxication in the absence of documented resolution after discontinuation of digoxin, or the presence of other clinical illnesses that could possibly account for those findings; (3) no intoxication--patients whose symptoms or ECG abnormalities were clearly explained by other associated clinical illnesses and persisted after withdrawal of digoxin. We identified only 43 patients (20%) with definite intoxication. The majority of patients discharged with the diagnosis of digoxin intoxication (133 or 60%) were classified as possibly digoxin intoxicated, and 43 patients (20%) had no clinical evidence to support this diagnosis. To estimate the incidence of digoxin intoxication, we also reviewed the medical records of 994 patients admitted in 1987 with heart failure. Of these, 563 were receiving digoxin and in 27 the diagnosis of digoxin intoxication was made by their clinicians. Our review showed that only four were definitely intoxicated (0.8%), and the diagnosis could not be excluded in another 16 (4%).(ABSTRACT TRUNCATED AT 250 WORDS)

Outcomes of patients hospitalized to a telemetry unit

To describe the clinical course of patients admitted to a nonintensive care telemetry unit and to determine whether telemetry identifies patients at risk for transfer to the intensive care unit (ICU), 467 patients hospitalized for cardiac monitoring in a nonintensive care telemetry unit were followed until death or discharge. The American College of Cardiology guidelines for telemetry use were applied: 65% of patients were class I (monitoring definitely indicated); 33% class II (probably indicated); and 2% class III (not indicated). In 5 patients (1%), telemetry contributed to the decision for a transfer to the ICU. In 462 patients, telemetry added no significant information. Thirty-eight patients (8.1%) were transferred to an ICU: 22 because of cardiac deterioration and 16 because of noncardiac clinical deterioration. Eighteen percent of patients in class I (95% confidence interval [CI], 14.1 to 22.8), 12% in class II (95% CI, 6.7 to 17), and none in class III (95% CI, 0 to 26) were transferred to the ICU (p = 0.03). Nine patients died (1.9%), 4 with terminal illness. Three patients died while on telemetry: 1 had metastatic lung cancer and 2 died suddenly of cardiac causes during initial evaluation on the ward. Telemetry identified the terminal rhythm in the 3 patients. Patients admitted to a non-ICU monitored ward with ischemic syndromes, heart failure, and arrhythmia rarely deteriorated. Patients who did deteriorate were recognized clinically without appreciable contribution from the monitoring process. It remains unproven that heart rhythm monitoring in general practice units improves patient care.

Evaluation of guidelines for the use of telemetry in the non-intensive-care setting.

To determine if the American College of Cardiology (ACC) cardiac monitoring guidelines accurately stratify patients according to their risks for developing clinically significant arrhythmias in non-intensive-care settings, we conducted a prospective cohort study of 2,240 consecutive patients admitted to a non-intensive-care telemetry unit over 7 months. Sixty-one percent of patients were assigned to ACC class I (telemetry indicated in most patients), 38% to class II (telemetry indicated in some), and 1% to class III (telemetry not indicated). Arrhythmias were detected in 13.5% of the class I patients, 40.7% of the class II patients, and 12% of the class III patients (p<.001). Telemetry detected an arrhythmia resulting in transfer to an intensive care unit in 0.4% of the class I patients, 1.6% of the class II patients, and none of the class III patients (p=.006). Telemetry led to a change in management for 3.4% of the class I patients, 12.7% of the class II patients, and 4% of the class III patients (p<.001). When patients with chest pain as the reason for admission were moved from class I to class II and patients with arrhythmias as the reason for admission were moved from class II to class I, more arrhythmias and more clinically significant arrhythmias occurred in class I patients and the trends from class I to class III were more consistent with the purpose of the guidelines. These findings indicate that when the ACC guidelines are reexamined, consideration should be given to changing them so they are more useful in non-intensive-care settings.

Activation of the coagulation system in women with mitral stenosis and sinus rhythm

Abstract Systemic embolism is a frequent complication in mitral stenosis (MS). 1 Its incidence increases with age and the presence of atrial fibrillation. 2,3 Although patients with MS and sinus rhythm can also develop systemic emboli, the frequency of this event is lower in these patients than in those with atrial fibrillation. 1 Patients with MS and atrial fibrillation are considered at high risk of systemic embolism and require anticoagulant therapy. 4 Because patients with MS and sinus rhythm are considered at low risk for systemic embolism, anticoagulant therapy is not routinely recommended. 4 It is desirable to identify patients with MS in sinus rhythm who are at high risk for systemic embolism. There are no reliable clinical or laboratory parameters available to stratify this risk. Recently developed assays are capable of detecting peptides released during activation of the coagulation cascade and thrombogenesis. 5,6 Measurement of these markers may be used to identify patients at risk for thromboembolism. This study was performed to test the hypothesis that there is activation of coagulation in patients with MS and sinus rhythm. Fibrinolytic activity was assayed by measuring D-dimers that are generated from plasmic degradation of cross-linked fibrin. 5 Thrombin activation was assayed by measuring thrombinantithrombin III complexes. 6

Transesophageal echocardiographic features of normal and dysfunctioning bioprosthetic valves

Transesophageal and transthoracic echocardiography and color flow Doppler were performed in patients with 42 normal and 20 dysfunctioning bioprosthetic mitral and aortic valves. Transesophageal echocardiography was superior to the transthoracic approach in delineating bioprosthetic valve cusps and the presence of valve thickening due to valve degeneration. In 27 clinically normal bioprosthetic mitral valves, regurgitation was demonstrated in three patients by the transthoracic approach and in seven by transesophageal study. Both transesophageal and transthoracic color flow Doppler demonstrated mitral regurgitation in 17 clinically regurgitant valves. The severity of mitral regurgitation was accurately assessed by the transesophageal study in all 13 patients who underwent angiography, whereas the transthoracic imaging underestimated valvular regurgitation in 7 of the 13 cases (54%). Bioprosthetic aortic valves were normal on clinical examination in 15 patients and were regurgitant in three others. Both transthoracic and transesophageal color flow Doppler were of equal value in observing and quantifying aortic regurgitation. In five clinically normal and regurgitant mitral and aortic valves, transesophageal color flow Doppler revealed eccentric regurgitant jets suggestive of paravalvular leak. This feature was not evident by the transthoracic approach. In conclusion, transesophageal echocardiography and color flow Doppler are superior to transthoracic imaging in estimating bioprosthetic mitral, but not aortic regurgitation, in differentiating valvular from paravalvular regurgitation, and in demonstrating thickened valves due to cusp degeneration.

Efficacy and Safety of Pravastatin in the Long-term Treatment of Elderly Patients With Hypercholesterolemia

PURPOSEnElevated cholesterol levels are a major risk factor for coronary heart disease, which remains a significant problem in patients beyond age 65 years. Because drug therapy for the control of hypercholesterolemia in elderly patients is frequently considered to be indicated, we investigated the efficacy and safety of pravastatin in the treatment of elderly subjects with primary hypercholesterolemia.nnnPATIENTS AND METHODSnIn this 96-week, multicenter, double-blind, placebo-controlled study, 142 subjects (95 women, 47 men) 64 to 90 years of age with elevated cholesterol levels despite dietary intervention were randomized to receive pravastatin 20 mg at bedtime or matching placebo (2:1). Dosage could be doubled after 8 weeks, a bile acid-binding resin could be added after 16 weeks, and nicotinic acid or probucol could be added after 32 weeks, as needed, to adequately lower the low-density lipoprotein cholesterol (LDL-C) levels.nnnRESULTSnSignificant reductions in the levels of LDL-C (-30.9%), total cholesterol (Total-C; -21.9%), and triglycerides (TG; -16.7%) and significant increases in the levels of high-density lipoprotein cholesterol (HDL-C; 11.3%) were noted in the group receiving pravastatin treatment at 16 weeks (P < or = 0.001 compared with baseline, P < or = 0.01 compared with placebo). The cholesterol-lowering effects of pravastatin were sustained throughout the 96 weeks of the trial. Pravastatin was well tolerated, with an overall incidence of adverse events nearly identical to that of placebo.nnnCONCLUSIONSnIn this study, pravastatin was well tolerated and effective in lowering LDL-C, Total-C, and TG and in raising HDL-C during long-term treatment of elderly patients with primary hypercholesterolemia.

Transesophageal Echocardiography in Evaluation of Atrial Masses

Clinical and transthoracic echocardiographic findings in 92 patients who had atrial mass lesions identified by transesophageal echocardiography were retrospectively analyzed. Transthoracic echocardiography failed to diagnose or misdiagnosed 16 patients with small (< 3 cm) atrial thrombi, patients with thrombi localized to the appendage, or patients with technically difficult studies. The 3 patients with atrial myxoma who were not detected or were misdiagnosed by transthoracic echocardiography had small tumors (< 3 cm) or origin from the free wall of the atrium away from the atrial septum. Transthoracic study also failed to diagnose or misdiagnosed normal anatomic variants in 17 of 32 patients. In conclusion, transesophageal echocardiography is superior to the transthoracic study in evaluating the etiology and significance of atrial mass lesions.

Idiopathic degeneration of the aortic valve: A common cause of isolated aortic regurgitation

To establish the etiology of isolated aortic valvular regurgitation, histologic examination was carried out on 27 consecutive surgically removed aortic valves from patients with aortic regurgitation. In 12 patients, the regurgitation was due to rheumatic or syphilitic valvular disease or a congenital bicuspid aortic valve. In the remaining 15, no etiology was apparent. In the latter group, seven aortic valves were identified by the surgeon as redundant and eight as thickened and retracted. Despite these gross differences, the histologic features of the 15 valves were similar and consisted of increased and disorganized elastic and collagen fibers, with variable quantities of acid mucopolysaccharide and calcium. Although small foci of myxomatous stroma were present, they did not differ substantially from those observed in age-matched competent aortic valves removed at necropsy, nor were they as extensive as described in reports of floppy aortic valves. Idiopathic degeneration was the most common cause of aortic regurgitation, occurring in more than half of the surgically treated patients. An underlying defect in the synthesis of collagen or elastic fibers, similar to that described in mitral valve prolapse, may be an important feature in aortic valve degeneration.

Clinical activities and satisfaction of general internists, cardiologists, and ophthalmologists

To define factors that affect the levels of practice satisfaction of different specialities, an observer recorded the activities of 15 physicians in practice (nine general internists, three cardiologists, and three ophthalmologists) as they examined 304 clinic patients. General internists reported less satisfaction with their clinics than did the other physicians and attributed their satisfaction primarily to successful social interaction in 54% of visits, while cardiologists most often derived satisfaction from intellectual stimulation (50%) and ophthalmologists from medical success (81%). The general internists whom the authors observed are less satisfied with clinical encounters than are cardiologists and ophthalmologists and derive satisfaction mostly from social interaction, not biomedical aspects of care.