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Research and Reviews in the Fastlane 057
This study compared bivalirudin to unfractionated heparin with the primary combined endpoint of death, CVA, reinfarction and target lesion revascularization. In spite of the fact that the trial was designed to favor bivalirudin (open-label), the authors found an increased rate in the primary outcome in the bivalirudin group (8.7% vs. 5.7%). Further proof that just because a drug is new, doesn’t mean it’s better. Recommended by: Anand Swaminathan Trauma, PediatricsAltgärde J, Redéen S, Hilding N, Drott P. Horse-related trauma in children and adults during a two year period. Scand J Trauma Resusc Emerg Med. 2...
Source: Life in the Fast Lane - November 10, 2014 Category: Emergency Medicine Authors: Soren Rudolph Tags: Cardiology Education Emergency Medicine Pediatrics Resuscitation Trauma Wilderness Medicine airway brain failure critical care General Surgery hypothermia Intensive Care prehospital recommendations Review Source Type: blogs

Research and Reviews in the Fastlane 054
Conclusions Wrong? (emlitofnote) Critical Care, CardiologyGuyton AC. Regulation of cardiac output. Anesthesiology. 1968; 29(2): 314-26. PMID: 5635884 The modern emphasis on echo might make you think that the heart determines cardiac output. This classic paper by Guyton shows that unless the heart is failing, it has a permissive role in determining cardiac output. The real determinants are (1) the degree of vasodilation of the peripheral vasculature, especially veins, and (2) the filling of the circulatory system, indicated by the mean systemic filling pressure. Gotta love those Guyton curves! Recommended by: Chris Nick...
Source: Life in the Fast Lane - October 20, 2014 Category: Emergency Medicine Authors: Nudrat Rashid Tags: Cardiology Clinical Research Education Emergency Medicine Infectious Disease Intensive Care Neurology Neurosurgery Obstetrics / Gynecology Orthopedics Pediatrics Trauma critical care literature R&R in the FASTLANE recommendat Source Type: blogs

Let’s stop the unnecessary treatment of heart disease
There are many reasons doctors suffer from burnout and compassion fatigue. One of the least-mentioned of these reasons is that much of what we do is so damn unnecessary. In the US, the land of excess everything, caregivers, especially cardiologists, spend most of our time treating human beings that didn’t need to have disease. Let’s be clear and honest: Lifestyle-related disease is largely unnecessary. These days, there is so much unnecessary disease that caregivers, especially cardiologists, rarely see it. We look past the obesity right to the cholesterol number and ECG. And then we pull out the prescription pad for t...
Source: Dr John M - October 3, 2014 Category: Cardiology Authors: Dr John Source Type: blogs

PhRMA and DOJ Go Back and Forth Over Off-Label Speech and the First Amendment
A whistleblower’s False Claims Act (FCA) suit in the Eastern District of California has caught the attention of the Pharmaceutical Research and Manufacturers of America (PhRMA) and subsequently the Department of Justice, both of whom have filed amicus curiae briefs in the federal court. PhRMA re-responded to DOJ just last week, underscoring the case's importance. See that response here: PhRMA-Brief-Solis-v-Millennium.  Whistleblower Complaint Frank Solis, a former sales rep at Schering-Plough (now part of Merck) and Millennium Pharmaceuticals, alleged that the two manufacturers illegally marketed ...
Source: Policy and Medicine - September 17, 2014 Category: American Health Authors: Thomas Sullivan Source Type: blogs

9 Hours of Chest Pain and Deep Q-waves: Is it too late for Thrombolytics? (Time Window for Reperfusion; Acuteness on the ECG)
Conclusion: An invasive strategy based on coronary stenting with adjunctive use ofabciximab reduces infarct size in patients with acute STEMI without persistent symptomspresenting 12 to 48 hours after symptom onset.This is a section on "Acuteness" that I wrote in a Chapter on Reperfusion therapy that I wrote with Bill Brady in Critical Decisions in Emergency and Acute Care Electrocardiography.  I have updated it here.Here are a couple posts that demonstrate the issue of acuteness.Acuteness—when is it too late for reperfusion?  In deciding on reperfusion, particularly on fibrinolytic therapy, it is imp...
Source: Dr. Smith's ECG Blog - August 28, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs

Ischemia guided myocardial revascularization
is an important aspect to be considered when myocardial revascularization is undertaken in the absence of significant symptoms. Disabling symptoms are often recognized as a definite reason for myocardial revascularization. In the absence of significant symptoms, unequivocal demonstration of ischemia would be the main reason for revascularization. The role of stress testing is to demonstrate ischemia and thereby the need for coronary angiography and revascularization if the vascular anatomy is suitable. Myocardial perfusion imaging is often considered as the gold standard for demonstration of ischemia. This is because it g...
Source: Cardiophile MD - August 26, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis MD, DM, FACC, FRCP Edin, FRCP London Tags: Angiography and Interventions Source Type: blogs

Out of hospital cardiac arrest
is an important mechanism of death through out the world and the survival rates are poor even in those who are resuscitated [Berdowski J et al. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation,2010: 81:1479–1487]. Survival to discharge range from two percent in Asia to eleven percent in Australia, with Europe and North America coming in between. It is well known that the critical links in the chain of survival for out of hospital cardiac arrest (or for any cardiac arrest for that matter) are early activation of emergency response, early c...
Source: Cardiophile MD - August 26, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis MD, DM, FACC, FRCP Edin, FRCP London Tags: General Cardiology Source Type: blogs

Arkansas Payment Improvement Initiative: The First Year
TweetEditor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Arkansas model. Arkansas payers and providers actively participated in the design of both the episodic payment and patient-centered medical home (PCMH) models the state has recently implemented. We’ve written about each of these components of the multi-payer Arkan...
Source: Health Affairs Blog - August 25, 2014 Category: Health Management Authors: William Golden, Joseph W. Thompson, Michael Motley, Mark Fendrick, Christopher Mathis, and Michael Chernew Tags: All Categories Medicaid Payment Reform States Source Type: blogs

Top stories in health and medicine, August 15, 2014
From MedPage Today: NSAIDs May Slow Breast Ca in Obese Women. Obese women with estrogen receptor-positive breast cancer had a 52% lower risk of recurrence when they regularly used aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). Mix of Kudos and Caution for Fecal DNA Test. Approval and imminent Medicare coverage of a DNA screening test for colorectal cancer generally received props from clinicians and researchers, who nonetheless cited continued patient aversion as the biggest obstacle to screening. Hospitals Seek To Help With ACA Premiums. Low-income consumers struggling to pay their premiums may soon be ...
Source: Kevin, M.D. - Medical Weblog - August 15, 2014 Category: Journals (General) Authors: Tags: News Cancer GI Source Type: blogs

Coronary artery perforation during PCI
Coronary artery perforation is an important but rare complication of percutaneous coronary intervention (PCI). Perforations can be caused by guide wires, angioplasty balloons or rotablator burr. It is a potentially life threatening complication depending on the severity and immediate management options available. Ellis classification of coronary artery perforations Ellis classification is based on angiographic appearance of the perforation [Ellis SG et al. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec;90(6):2725-30]. Grade I: Extraluminal cr...
Source: Cardiophile MD - August 12, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis MD, DM, FACC, FRCP Edin, FRCP London Tags: Angiography and Interventions Coronary Interventions Source Type: blogs

Transvenous IVUS guided PCI for CTO
Transvenous IVUS (intravascular ultrasound) guided PCI (percutaneous coronary intervention) for CTO (chronic total occlusion) is a novel technique in which the IVUS catheter is introduced through the cardiac vein parallel to the target artery [Takahashi Y et al. Transvenous IVUS-guided percutaneous coronary intervention for chronic total occlusion: a novel strategy. J Invasive Cardiol. 2013;25:E143-6]. Follow up angiogram showed good result, maintaining after eight months. The post Transvenous IVUS guided PCI for CTO appeared first on Cardiophile MD. (Source: Cardiophile MD)
Source: Cardiophile MD - August 12, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis MD, DM, FACC, FRCP Edin, FRCP London Tags: Angiography and Interventions Coronary Interventions Source Type: blogs

Polygon of confluence in IVUS
Polygon of confluence is a term often used in intravascular ultrasound (IVUS) imaging of the coronary arteries. It is the confluence of left main coronary artery (LMCA), left circumflex (LCX) and left anterior descending (LAD) coronary artery. The 5,6,7,8 criteria mentions that the LCX should have an area of 5 mm2, LAD 6 mm2, polygon of confluence 7 mm2 and LMCA 8 mm2. If these areas are achieved after an IVUS guided PCI (percutaneous coronary intervention) of distal LMCA, that is taken as a good result. The minimum lumen area (MLA) in the polygon of confluence can be taken as a surrogate of overall severity of the left m...
Source: Cardiophile MD - August 11, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis MD, DM, FACC, FRCP Edin, FRCP London Tags: General Cardiology 5-6-7-8 criteria in IVUS intravascular ultrasound LAD LCX left anterior descending coronary artery left circumflex coronary artery left main coronary artery LMCA PCI Percutaneous coronary intervention Source Type: blogs

The difference between Left Main occlusion and Left Main insufficiency
There are many publications stating that ST elevation in lead aVR, with diffuse ST depression elsewhere, is due to "left main occlusion."  This is even stated in the lastest 2013 ACC/AHA STEMI guidelines, and they reference an article by Jong et al. (Int Ht J 2006; 47(1):13-20.) as evidence.  If you go read that article, "occlusion" was defined as any stenosis greater than 50%.  That is not occlusion, which is 100%.  There are many other articles that confuse Left Main occlusion with Left Main insufficiency, and these are the sources of the mistaken belief that this ECG pattern reflects LM occlusio...
Source: Dr. Smith's ECG Blog - August 2, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs

What are the situations in which patient is taken up for CABG following an attempted primary PCI?
What are the situations in which patient is taken up for coronary artery bypass grafting (CABG) following an attempted primary percutaneous coronary intervention (PCI)? Coronary anatomy not suitable for PCI Coronary artery perforation Inability to cross a critical lesion causing recurrent ischemia (Source: Cardiophile MD)
Source: Cardiophile MD - July 28, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiac Surgery CABG Coronary anatomy not suitable for PCI Coronary artery bypass grafting Coronary artery perforation Inability to cross a critical lesion causing recurrent ischemia Primary PCI primary percutaneous coronary intervention Source Type: blogs

Subacute AnteroSeptal STEMI, With Persistent ST elevation and Upright T-waves
DiscussionWhen there is full thickness infarction, there is epicardial inflammation (post-infarction regional pericarditis), and the myocardium is at risk of "rupture."  The term "rupture" makes it sound like some sort of explosion or massive blowout, but it is usually a small, slow leak that, over time, can cause tamponade and death.  Rupture can be either free wall rupture (causing tamonade) or septal rupture, causing ventricular septal defect with left to right flow and resulting pulmonary edema and shock.  If detected early by ultrasound, the patient can be saved.  Our own Dave Plummer of HCMC repor...
Source: Dr. Smith's ECG Blog - July 18, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs