Critical pathways in cardiology
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Prognostication beyond troponin levels in patients with acute atrial fibrillation (AF) is still unclear. ⋯ In patients with acute AF, abnormal troponin levels add prognostic value to clinical parameters in the short term; dysglycemia and known vascular disease in the long term.
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The number of cases of out-of-hospital cardiac arrest is estimated to be 300,000/year in the United States. Two landmark studies published in 2002 demonstrated that therapeutic hypothermia decreased mortality and improved neurological outcome after out-of-hospital cardiac arrest. Our institutional pathway for the management of survivors of cardiac arrest stresses teamwork involving multiple disciplines, including cardiology, critical care, nursing, neurology, infectious diseases, physical therapy, social work, and pastoral care. ⋯ This conference serves as a means to review our experience, educate clinicians, involve all healthcare providers in the outcome, and provide a model of communication and professionalism to trainees. During review of our experience, we noted the small number of women undergoing therapeutic hypothermia, accounting for only 21% of all patients undergoing this therapy after cardiac arrest. This led to a conference that focused on cardiac disease and cardiac arrest in women.
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The ability to risk stratify patients presenting to the emergency department (ED) with potential acute coronary syndrome (ACS) is critical. The thrombolysis in myocardial infarction (TIMI) risk score can risk stratify ED patients with potential ACS but cannot identify patients safe for ED discharge. The symptom-based HEART score identifies very low-risk patients. Our hypothesis was that patients with a TIMI score of 0 or 1 may be stratified further with the HEART score to identify a group of patients at less than 1% risk of 30-day cardiovascular events. ⋯ At all levels of TIMI score, the HEART score was able to further substratify patients with respect to 30-day risk. A HEART score of 0 in a patient with a TIMI of 0 identified a group of patients at less than 1% risk for 30-day adverse events.
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To study the reperfusion strategies currently being used in the treatment of ST-elevation myocardial infarction (STEMI) at an academic medical center in a developing country and to analyze the door-to-balloon time (DBT) in those patients undergoing primary percutaneous coronary intervention (PCI). ⋯ There was a significant increase in the utilization of primary PCI for reperfusion of STEMI in this academic medical center in a developing country. However, achieving a target DBT ≤90 minutes was suboptimal. Future studies are needed to analyze the logistic factors associated with delayed reperfusion to institute policies and systems that can enhance the efficacy of primary PCI as a reperfusion modality in these countries.
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Telemetry monitoring is often overused in the inpatient setting. This has led to overcrowding of telemetry beds, increased wait times in the emergency department, and inefficient allocation of hospital resources. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines exist to guide appropriate utilization of cardiac monitoring. We sought to investigate the effect of the institution of an electronic ordering system (EOS) on adherence to guideline-based telemetry use. ⋯ The institution of an EOS significantly improved compliance with ACC/AHA guidelines for cardiac monitoring at the time of admission. However, compliance worsened after the initial 48 hours, which may have been due to the ease of online reordering with our EOS. Clinically significant events were only observed in patients who met criteria for monitoring. EOS can be a useful tool to improve adherence to guideline-based utilization of hospital resources.