Prescription Delay Following Stent Implantation Is a Common and Deadly Problem
After receiving a stent, many patients delay or fail to fill their prescription for clopidogrel or another antiplatelet agent. Now, a study published in the Journal of the American Heart Association offers evidence that this problem is widespread and often leads to serious consequences. Researchers analyzed data from all stent implantations performed in British Columbia from 2004 through 2006. In all, 15,629 stents were implanted: 3,599 patients received at least one drug-eluting stent (DES), and 12,030 received bare metal stents (BMS) alone. Nearly a third of the patients in each stent group did not fill their prescr...
Source: CardioBrief - May 28, 2014 Category: Cardiology Authors: Larry Husten Tags: Interventional Cardiology & Surgery Policy & Ethics clopidogrel compliance prescriptions stents Source Type: blogs
True Positive ST elevation in aVL vs. False Positive ST elevation in aVL
Case 1. A woman in her 60s with no prior history of CAD presented with 3 hours of sharp, centrally located chest pain with radiation to the anterior neck, with associated nausea. She had known HTN and DM. She appeared to be in distress. She was given sublingual NTG with improvement, but there was not complete resolution.Here was here initial ECG:There is ST elevation in I and aVL, with inferior reciprocal ST depression in all of II, III, and aVF, and a down-up T-wave in aVF (a sign that is very specific for ischemia). There is also ST depression in V3-V6. This ECG is diagnostic of ischemia.It ...
Source: Dr. Smith's ECG Blog - May 12, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Battle of the Bulge: Olecranon Bursitis
Olecranon bursitis, also called baker’s or Popeye elbow, can be a painless or an irritating condition involving the bursa located near the proximal end of the ulna in the elbow over the olecranon. Normal bursae sacs generally are filled with a small amount of fluid, which helps the joint remain mobile. The sac can swell under the soft tissue from overuse or when the area sustains an injury from a bump or fall.
Normal bursae are usually small, but they can grow to be quite large, swollen, and occasionally even infected when they become irritated or inflamed. The swelling is obvious because the space in this area is lim...
Source: The Procedural Pause - May 6, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Battle of the Bulge: Olecranon Bursitis
Olecranon bursitis, also called baker’s or Popeye elbow, can be a painless or an irritating condition involving the bursa located near the proximal end of the ulna in the elbow over the olecranon. Normal bursae sacs generally are filled with a small amount of fluid, which helps the joint remain mobile. The sac can swell under the soft tissue from overuse or when the area sustains an injury from a bump or fall.
Normal bursae are usually small, but they can grow to be quite large, swollen, and occasionally even infected when they become irritated or inflamed. The swelling is obvious because the space in this area is l...
Source: The Procedural Pause - May 6, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Unstable Angina: Dr. Braunwald asks if it is time for a Requiem
This article prompted some recent Tweets about whether Unstable Angina (UA) still exists in the age of sensitive biomarkers. Don't all ACS rule in by serial trops now? UA certainly does still exist, at least for now, because in the U.S. we do not yet have FDA approval for high sensitivity troponin (hscTnI). And we do not yet know for certain whether hscTnI will abolish UA, or just diminish the number of patients with troponin (-) ACS.Perhaps when we get hs troponin in the U.S. (not yet), it will be exceedingly uncommon, but with the use of contemporary troponin assays, it is an important phenomenon still.Below are so...
Source: Dr. Smith's ECG Blog - April 11, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain in a patient with previous inferior STEMI. Scrutinize both the ECG and the history!
I was looking through a stack of ECGs (I can't help myself) and saw this one, which caught my eye:What do you think? Computerized QRS duration is 120 ms.My thought was that it looked like there was likely very subtle anterior injury. In spite of the slightly prolonged conduction, I applied the anterior STEMI calculator (see sidebar excel applet, or "subtleSTEMI" iphone app), using:1. ST elevation at 60 ms after the J-point in lead V3: 2 mm (it is probably really 2.5 mm, but I wanted to be conservative)2. computerized QTc = 413 ms3. R-wave amplitude in V4 = 9 mmResult = 23.83 (greater than 23.4 and thus indicati...
Source: Dr. Smith's ECG Blog - April 9, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
A Very Unstable Angina. No STEMI present, but needs the cath lab now.
An elderly woman with h/o diabetes and hypertension but no prior cardiac history had been having exertional chest pain for months, though with a normal stress test. She had onset at rest of severe substernal chest pressure radiating to the neck. There was associated SOB and diaphoresis. EMS came and recorded this ECG:What is it? See annotated ECG below.I have put arrows where I think the P-waves are. They march out regularly, but are non-conducting. This is complete, 3rd degree, AV block. The escape is regular at a rate of about 36 and looks like a right bundle branch block and lef...
Source: Dr. Smith's ECG Blog - April 4, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
A Non STEMI that needs the cath lab now.
A male in his 60's called 911 for chest pain. He had some cardiac risk factors including hypertension, on meds, but no previous coronary disease. His pain was intermittent and he was vague about when it was present and when it was resolved. Here is his prehospital ECG:Diagnosis? He had an immediate ED ECG:There is artifact, but the findings appear to be largely gone nowThe diagnosis is acute MI, but not STEMI. There is slight ST elevation in lead III with reciprocal ST depression in aVL. The T-wave is inverted in III, indicating reperfusion (what I like to call "inferior Wellens' s...
Source: Dr. Smith's ECG Blog - April 2, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
A New Novartis Heart Failure Drug Might Be A Blockbuster
I try to avoid using words like “blockbuster” and “breakthrough” when writing about new drugs and treatments. I’ve been disappointed too many times. But, though they’ve been in short supply lately in cardiovascular medicine, sometimes there really are breakthroughs and blockbusters. In my career writing about cardiovascular medicine I’ve seen the introduction of the ACE inhibitors, statins, stents, ICDs, and clopidogrel, among others. All of these became multibillion-dollar products. Now there’s a new candidate that just might join this group. I’ll tell you why, but I c...
Source: CardioBrief - April 1, 2014 Category: Cardiology Authors: Larry Husten Tags: Heart Failure People, Places & Events Policy & Ethics ACE inhibitors Angiotensin Receptor Neprilysin Inhibitor enalapril LCZ696 Novartis Source Type: blogs
Plavix and The Five O
Hawaii attorney general sues makers of drug Plavix alleging unfair and deceptive marketingHawaii Attorney General David Louie filed a lawsuit Wednesday in 1st Circuit Court against Bristol-Myers Squibb and Sanofi-Aventis, the manufacturers and distributors of the drug Plavix, alleging unfair and deceptive marketing of the blood-thinning drug to Hawaii consumers.The suit alleges that manufacturers of Plavix, a “blockbuster antiplatelet” drug aimed at preventing strokes and heart attacks, began questionable marketing of the drug back in 1998 for not disclosing information related to how certain g...
Source: PharmaGossip - March 20, 2014 Category: Pharma Commentators Authors: insider Source Type: blogs
Pseudonormalization of Wellens' Waves
A male in his 60's complained of intermittent chest pain all day. He was vague as to whether there was active chest pain, but it was definitely better at the time I talked to him.Here is his initial ECG:There is minimal ST elevaton and there are subtle T-wave inversions in V2-V5, highly suggestive of Wellens' syndromeIn Wellens' syndrome, the artery is open. T-wave inversion, as I've pointed out countless times (and hope I'm not belaboring) is indicative of reperfusion of the infarct-related vessel.BP was elevated, pulse lowered to 45. He received ASA, Plavix 600mg, Heparin, and a Nitro drip.As a matter o...
Source: Dr. Smith's ECG Blog - March 14, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
The LITFL Review 129
The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle to find the most fantastic EM/CC FOAM (Free Open Access Meducation) around.
Welcome to the 129th edition, brought to you by:
Kane Guthrie [KG] from LITFL
Tessa Davis [TRD] from LITFL and Don’t Forget The Bubbles
Brent Thoma [BT] from BoringEM, and ALiEM
Chris Ni...
Source: Life in the Fast Lane - March 11, 2014 Category: Emergency Medicine Doctors Authors: Chris Nickson Tags: Education eLearning Emergency Medicine Featured Intensive Care Pediatrics Toxicology #FOAMped #FOAMtox #meded FOAMcc FOAMed LITFL R/V LITFL review Source Type: blogs
Incessant Regular Wide Complex Tachycardia
A male in his 50's presented after a witnessed syncopal episode. He reported multiple syncopal events over the last 1-2 months with increasing frequency, as well as recent fatigue. He had a remote history of in-hospital cardiac arrest during surgery. He had no anginal symptoms, no CP or SOB. Prehospital tracings were concerning for monomorphic sustained regular wide complex tachycardia with repeated runs of bigeminy, and no clear evidence of a current of injury.In the ED, he had VT on the monitor, and the following 12-lead ECG:There is a regular monomorphic wide complex tachycardia with no P-waves. The co...
Source: Dr. Smith's ECG Blog - March 11, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
A Stressing Situation
A 64-year-old woman presented to the emergency department with two days of severe nausea, numerous episodes of vomiting, and progressively worsening right upper quadrant/epigastric abdominal pain. She was continuously spitting clear secretions into an emesis bag on arrival in triage. Her 8/10 dull ”ripping” pain originated in the right upper quadrant and radiated in a band-like pattern to her epigastrium. She was not experiencing any chest pain or shortness of breath. Her medical history included hypertension, type 2 diabetes mellitus, recurrent acute pancreatitis secondary to hyperglycemia, peripheral artery disease, ...
Source: Spontaneous Circulation - March 10, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Stressing Situation
A 64-year-old woman presented to the emergency department with two days of severe nausea, numerous episodes of vomiting, and progressively worsening right upper quadrant/epigastric abdominal pain. She was continuously spitting clear secretions into an emesis bag on arrival in triage. Her 8/10 dull ”ripping” pain originated in the right upper quadrant and radiated in a band-like pattern to her epigastrium. She was not experiencing any chest pain or shortness of breath. Her medical history included hypertension, type 2 diabetes mellitus, recurrent acute pancreatitis secondary to hyperglycemia, peripheral artery disease, ...
Source: Spontaneous Circulation - March 10, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
