Jeffrey A. Rosenblatt

A randomized, placebo-controlled trial of early eptifibatide for non-ST-segment elevation acute coronary syndromes.

BACKGROUND The acute benefits of platelet glycoprotein IIb/IIIa inhibitors for non-ST-segment elevation acute coronary syndromes (NSTE ACS) remain unclear. METHODS In this pilot trial, 311 patients with NSTE ACS were randomly assigned in the emergency department to double-blinded therapy with eptifibatide or placebo for 12 to 24 hours before crossover to open-label eptifibatide. Serial creatine-kinase MB (CK-MB) and quantitative cardiac troponin T levels were collected during the first 24 hours to assess the impact of early platelet glycoprotein IIb/IIIa blockade on infarct size as measured by cardiac markers. RESULTS Median peak CK-MB (10.3 vs 11.8 ng/mL; P =.71) and peak quantitative cardiac troponin T levels (0.2 vs 0.3 ng/mL; P =.95) were similar between treatment groups, respectively. Median calculated peak CK-MB values (41 vs 40 ng/mL; P =.72) and area under the CK-MB curve measurements (980 vs 764 microg/min/L; P =.68) from curve-fitting analyses that could be performed in 106 of 311 patients were also similar. CONCLUSIONS In this pilot trial, early administration of eptifibatide in the emergency department did not modulate serologic measurements of infarct size in patients with NSTE ACS.

Asystole following regadenoson infusion in stable outpatients.

Regadenoson is a selective A2A receptor agonist approved for use as a pharmacologic stress agent for myocardial perfusion imaging after several multicenter trials demonstrated its equivalence in diagnostic accuracy for the detection of coronary artery disease and a decreased incidence of serious side effects as compared to adenosine. Recently, the FDA released a safety announcement advising of the rare but serious risk of heart attack and death associated with regadenoson and adenosine in cardiac stress testing, particularly in patients with unstable angina or cardiovascular instability. We report two cases of asystole with hemodynamic collapse in stable outpatients soon after receiving a standard regadenoson injection. The prevalence of potentially life threatening bradycardia, including asystole, associated with the use of regadenoson may be greater than previously expected. These cases highlight the need for cardiac stress labs to anticipate the potential for serious side effects with all patients during the administration of coronary vasodilators.

ASNC model coverage policy: single photon myocardial perfusion imaging.

This document is intended as a model coverage policy for SPECT myocardial perfusion imaging (MPI) studies and delineates under what clinical indications such a study is appropriate to administer to patients. This document examines a variety of clinical indications and symptoms that a common patient would present with and supports the use of performing such a study by crossreferencing the indication with the multi-society appropriate use criteria for radionuclide studies developed by the American College of Cardiology (ACC)/ASNC in 2005, and subsequently revised in 2009. In addition, the use of SPECT MPI in patients with the indications delineated in the policy is supported by references to an abundance of literature which supports the use of this study in the provided scenarios. Finally, we have provided the ICD-9 codes which correlate to each of the indications to demonstrate what codes, or ranges of codes, are appropriate for each clinical indication.

Rest myocardial perfusion imaging in a patient with atypical chest pain and a nondiagnostic electrocardiogram.

ACC/AHA guidelines assign a class I indication for use of myocardial perfusion imaging (MPI) for the evaluation of chest pain in patients with acute coronary syndromes and a nondiagnostic ECG. However, MPI is not a widely used modality for the evaluation of patients who present to the ER with chest pain and an intermediate pretest probability for coronary artery disease.

Acute chest pain imaging in the outpatient setting

ConclusionAcute SPECT imaging with Tc-99m sestamibi is an emerging, cost-effective stratagem for selected patients arriving at the emergency department with chest pain. To date, the cohort of patients studied have included those who arrive at the emergency department with typical chest pain and a normal or nondiagnostic electrocardiogram. This application could be extended to other clinical settings. The current case demonstrates that in an outpatient setting, a severe rest SPECT perfusion defect in a symptomatic patient with a nondiagnostic electrocardiogram prompted timely hospitalization and revascularization. The resting defect was consistent with jeopardized, viable myocardium as it normalized after revascularization.

Transient Hypertrophic Obstructive Cardiomyopathy During Pregnancy

Hypertrophic obstructive cardiomyopathy (HOCM) is a primary myocardial disease with typical echocardiography features of asymmetric septal hypertrophy and evidence of left ventricular outflow tract obstruction. The natural history of HOCM is characterized by a slow progression of symptoms and a significant annual mortality rate. We report an unusual case of transient HOCM during pregnancy with evidence of total resolution postpartum.