The main reason for getting a TEE in a patient with ischemic stroke is to find out if that patient has an indication for warfarin anticoagulation. You can begin the selection process by excluding patients who already have an obvious indication for warfarin (e.g. atrial fibrillation) and those who have a contraindication for warfarin.
Among the remaining patients only those with cryptogenic stroke are likely to need a TEE. This is an old paper demonstrating a high yield for TEE in finding an indication for warfarin in such patients. Here is a new study documenting similar findings:
The TOAST classification may be helpful in the determination of cryptogenic stroke.
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When will you request TEE in Ischemic Stroke?
June 14, 2009
How well do you treat hypertension?
Not all docs are above average but, according to this study, most of us tend to think we do a better job of treating HT than we actually do. Moreover, when the patient doesn’t reach goal we blame it on “noncompliance.Read more..
The most forgotten Lead= aVR
The most neglected electrocardiographic lead may be the most important in some patients with ACS.Often relegated to the status of placeholder in the electrocardiogram, aVR may contain the critical data for the diagnosis of a number of conditions. A review in the American Journal of Emergency Medicine highlights pericarditis, left main coronary obstruction, orthodromic tachycardia and acute tricyclic antidepressant poisoning. From Medscape Emergency Medicine Viewpoints:
The takeaway point is simple: When patients with ACS, including non-STE ACS, demonstrate STE in lead aVR, the aggressiveness of early management must be
increased. These patients have more complex coronary lesions and will likely benefit from earlier invasive therapy.
Additional references:
ST elevation in aVR as a sign of left main coronary artery obstruction.
Review of electrocardiographic clues obtainable from aVR (JACC).
Classic paper on the electrocardiographic changes of pericarditis.
The electrocardiogram in non cardiac conditions..
The extended time window for IV TPA in acute ischemic stroke
The Best Blood Pressure Medicine
June 12, 2009
A recent meta-analysis published in the British Medical Journal compared the efficacy of different classes of blood pressure medications in preventing coronary artery disease (CAD) and stroke.
The investigators found that all blood pressure medicines are equally effective in preventing CAD and stroke.
Beta Blockers (e.g. metoprolol, carvedilol) were more effective in preventing future episodes of heart attacks in people who already had one. For primary prevention of CAD beta blockers were no more effective than other blood pressure lowering medications.
For 10mm reduction in systolic BP and 5mm diastolic BP:-
Risk reduction in CAD = 22%
Risk reduction in stroke = 41%
Calcium channel blockers (e.g. amlodipine) were slightly more effective in preventing stroke than other classes of medicines.
Read BMJ meta analysis..
Cola and Muscle weakness
Chronic consumption of large amounts of cola soft drinks may cause hypokalemia and muscle weakness.. Watch out for hypokalemia in cola drinkers! Read More..
Tamsulosin and cataract surgery
Tamsulosin use within 14 days of cataract surgery associated with significant postoperative adverse events.. Cataract patients have BPH.. Read this study..
Pneumococcal vaccine fails
Prophylactic Revasculrisation and Surgery
Pre operative prophylactic revascularisation is done frequently in high risk cardiac patients. Studies have shown no long term nor short term benefits..Read this article..
Abalation Deaths
Dont think abalation of Atrial Fibrillation is nor risky. Death as an complication happens in 1 in 1000 patients..Read this study.
Aspirin and Primary prevention
Lancet Metanalysis: Using aspirin in the primary prevention of cardiovascular disease is "of uncertain net value.. Read now..
Familial Aortopathy
Primary PCI and Bleeding
Pimary PCI has been changed the management of patients with Acute MI with an added cost. Significant bleeding after cardiac cath due to anti-platelet agents are an important predictor of mortality.. Read this article..
PTU and Liver Injury
Propylthiouracil associated with higher risk of liver damage compared to Methimazole in the treatment for hyperthyroidism" FDA warns..Read now..
Stroke After TIA
TIA patients are at high risk of recurrent stroke. Almost half of all strokes that occur during the 7 days after a transient ischemic attack (TIA) happen within 24 hours..ABCD2 score is reliable in the hyperacute phase.. Read this article published in Neurology..
Keep antibiotic Working
Nationwide campaign in France - “Keep Antibiotics Working” successful in reducing unnecessary antibiotic prescriptions.. Read more.......
Beta Blocker in CHF
Use of Beta blocker therapy has improved survival of patients with CHF. Magnitude of heart rate reduction is associated with survival benefit and not dose of beta blocker in heart failure. Read this meta analysis published in Annals of Internal medicine;; more..
PPI and Pneumonia
Most of us have been guilty of prescribing proton pump inhibitors (PPIs) to our hospitalized patients without prudently assessing their need and often disregarding the actual indications for their use. Perhaps the article titled “Acid-Suppressive Medication Use and the Risk for Hospital-Acquired Pneumonia,” published in this week’s JAMA, will motivate us to reconsider prescribing PPIs without giving due consideration to potential adverse events.
According to the study, an estimated 40-70% of medical inpatients are treated with either a PPI or H2-receptor antagonist during hospitalization; approximately 50% of the patients are newly started on these medications, and nearly 50% of these patients are discharged on a PPI. While several outpatient studies suggest an increased risk of community-acquired pneumonia in patients receiving acid-suppressive medications, no large-scale studies exist to determine the association between acid-suppressive medications and hospital-acquired pneumonia. Herzig, et al, conducted a large, prospective cohort study from January 2004 through December 2007, including patients over the age of 18 (median age 54) admitted to the hospital for at least 3 days. Excluded from this study were all patients who spent any time in the ICU. The final cohort consisted of 63,878 admissions, of which 52% received either a PPI (83%) or H2-receptor antagonist (23%) during hospitalization. The primary outcome of hospital-acquired pneumonia occurred in 2219 admissions (3.5%). In the group of patients receiving acid-suppressive medications, there was a higher unadjusted incidence of hospital-acquired pneumonia compared to the unexposed group: 4.9% vs 2.0%, OR 2.6 (95% CI, 2.3-2.8). Additionally, there was a significant association for both aspiration pneumonia and non-aspiration pneumonia, with the diagnoses based on ICD-9 codes used at the time of hospitalization. After adjusting for potential confounders, the adjusted OR for hospital-acquired pneumonia in the group receiving acid-suppressive therapy was 1.3 (95% CI, 1.1-1.4). Interestingly, after adjustment, the association was significant only for PPI’s and not H2-receptor antagonists. Overall, the use of acid-suppressive medications, in particular PPIs, was associated with a 30% increased odds of developing hospital-acquired pneumonia. Given the estimated mortality rate of 18% for hospital-acquired pneumonia, these results are somewhat alarming. Thus, this study clearly emphasizes the need to closely examine our patient’s medication regimen at the time of hospitalization and determine if a PPI is truly warranted.
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