Archive for the ‘Uncategorized’ Category

Video: Aug 2011 lecture Anesthesia for Carotid Revascularization

Tuesday, August 23rd, 2011

Medical University of South Carolina Grand Rounds

Dr. John E. Ellis

New antiplatelet drug may facilitate periop management of coronary stent patients, if approved by FDA

Friday, July 30th, 2010

From Medscape Cardiology:

July 28, 2010 (Updated July 30, 2010) (Adelphi, Maryland) — TheFDA Cardiovascular and Renal Drugs Advisory Committee voted to recommend approval of antiplatelet drug ticagrelor (Brilinta, AstraZeneca) for preventing thrombotic events in patients with acute coronary syndromes (ACS).

The potential advantage of ticagrelor is that, unlike clopidogrel and prasugrel (Effient, Lilly/Daiichi), it is not a thienopyridine and can be “turned on and off” much faster than those agents; it therefore can prevent clots day-to-day without putting patients at higher risk for bleeding should they need surgery.









WHAT’S THE BEST STRESS TEST?

Sunday, June 20th, 2010

From the 2010 World Congress of Cardiology:


ECG Patterns During Sexual Intercourse in Patients with Coronary Artery Disease

Vadim Kuznetsov, Victor Todosiychuk, Sergei Velizhanin, Tyumen Cardiology Center (Tyumen, Russian Federation)

Introduction: Assessment of the influence of sexual activity on cardiovascular system in patients with coronary artery disease (CAD) still remains controversial. The purpose of our investigation was to assess the ECG patterns during sexual intercourse (SI) in patients with CAD. 

Methods: 12 male volunteers (age 55.3_8.8 years) with stable CAD (stable angina class II/III according to the Canadian Cardiovascular Society) underwent 24-hour ECG monitoring. The patients recorded the time of the start and finish of SI. We compared the ECG patterns during SI and daily physical exercise (PE). 

Results: The peak of heart rate was significantly higher during SI compared with PE (147.7_15.2 vs 132.3_7.3 beats/min, p_0.002). 8 patients showed ST segment depression both in SI and PE. The level of ST depression was higher in SI (1.5_0.2 vs 1.1_0.1 mm, p_0.001). Combination of angina pectoris and ST depression was recorded only in 2 patients during SI compared with 4 patients during PE. 2 patients had episodes of atrial fibrillation, 1 had ventricular bigeminy and frequent ventricular premature beats during SI.

Conclusion: In patients with CAD SI was associated with heart rhythm disorders and silent transient myocardial ischemia probably more severe in comparison with ischemia during daily PE.

CAROTID ENDARTERECTOMY BEATS STENTING/ANGIOPLASTY IN CREST

Thursday, May 27th, 2010

From Physician’s First Watch for May 27, 2010 David G. Fairchild, MD, MPH, Editor-in-Chief

“CREST Trial Points to Endarterectomy as Preferred Stroke Preventive Strategy

A comparison of endarterectomy versus stenting in treating carotid artery stenosis shows that stent recipients are at higher risk for stroke within 30 days of the procedure, according to a New England Journal of Medicine study released online.

Investigators in the CREST trial randomized some 2500 patients with carotid artery stenosis to either stenting or endarterectomy. After a median follow-up of 2.5 years, the groups showed no significant difference in the primary endpoint — a composite of stroke, myocardial infarction, or death from any cause during the periprocedural period, or ipsilateral stroke within 4 years.

However, the 4-year rate of stroke or death significantly favored endarterectomy. When the individual outcomes were examined, there were significantly more periprocedural strokes after stenting, and more MIs after endarterectomy.

Editorialists conclude that “endarterectomy remains the preferred treatment for most patients.”

NEJM article (Free)

NEJM editorial (Free)

TROPONIN RELEASE AFTER VASCULAR SURGERY IS OMINOUS

Saturday, May 15th, 2010

The prolific group from Erasmus published a systematic review that analyses thresholds of troponin release that represent perioperative myocardial ischemia in vascular surgery patients.

The slideshow below shoes only info for TnI; see full manuscript for TnT data (doi:10.1016/j.ejvs.2010.03.014)

THE RCRI DOES NOT PERFORM SO WELL IN VASCULAR SURGERY PATIENTS

Friday, April 30th, 2010

The RCRI has been a standard part of preop eval and the AHA/ACC Periop Guidelines for close to a decade.

The prolific Toronto group shows in a meta-analysis that the RCRI (revised cardiac risk index) performs less well in risk prediction in vascular surgery patients than in other noncardiac surgery patients.

Prediction of cardiac events after vascular noncardiac surgery was less accurate:
AUC, 0.64 [CI, 0.61 to 0.66];
sensitivity, 0.70 [CI,0.53 to 0.82];
specificity, 0.55 [CI, 0.45 to 0.66];
positive likelihood ratio, 1.56 [CI, 1.42 to 1.73];
negative likelihood ratio, 0.55 [CI,0.40 to 0.76]
… future studies should evaluate whether an alternative clinical index can be developed that combines the ease of use of the RCRI with improved predictive accuracy.
Stayed tuned for future work on refinements to RCRI.

NEJM VIDEO: “Ultrasound-Guided Internal Jugular Vein Cannulation.” Paul Barash and colleagues

Friday, April 23rd, 2010

Ultrasound-Guided Internal Jugular Vein Cannulation

Rafael Ortega, M.D., Michael Song, M.D., Christopher J. Hansen, M.A., and Paul Barash, M.D.

http://content.nejm.org/cgi/content/short/362/16/e57

PEDAL EDEMA MAY MOVE TO THE NECK IN SUPINE PATIENTS, EXACERBATING OSA

Friday, April 23rd, 2010

A very thought-provoking manuscript and editorial in Circulation suggests that pedal edema fluid may be recruited to the neck when patients lay supine, exacerbating OSA.

It is known that OSA increases the likelihood of CHF, and that many CHF patients have OSA.

In the perioperative period, we general implicate opiates for worsening OSA; maybe fluid therapy has a role as well?

Nocturnal Rostral Fluid Shift: A Unifying Concept for the Pathogenesis of Obstructive and Central Sleep Apnea in Men With Heart Failure
Dai Yumino, Stefania Redolfi, Pimon Ruttanaumpawan, Mao-Chang Su, Stephanie Smith, Gary E. Newton, Susanna Mak, and T. Douglas Bradley
Circulation 2010 121: 1598-1605

BETA BLOCKADE IN THE SETTING OF ANEMIA MAY BE PROBLEMATIC

Wednesday, April 7th, 2010

Following up on work presented at the ASA a couple of years ago, the group from Toronto reports (Anesthesiology. 112(1):25-33, January 2010), using propensity-matched cohorts, that beta-blocked vascular surgery patients whose hemoglobins fall more than 35% with surgery have INCREASED rates of MACE (major adverse cardiac events).  Unfortunately, this is not an RCT, and there is confounding.  Still, the story gets more complicated!  See my lecture notes from December 2009 PGA meeting.

The accompanying editorial by Weiskopf suggests:

Importantly, as noted by the authors, this was not a prospective trial, and the very act of ordering a test for troponin (not mandated, but ordered according to clinician desires) confounded the results: that is, the unknown rationale for a measurement had a huge confounding inappropriate17

Until better data are available, although [beta]-adrenergic antagonists seem to protect the myocardium of high-risk patients and may well be of lesser or no efficacy for patients at lesser risk, it would seem prudent to avoid those agents that substantially impair the cardiac response to acute severe anemia when that or substantial hemorrhage is anticipated.

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Wednesday, April 7th, 2010

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