Resources in Cardiology

Remember "Cards on the Hill"?  It was a resource for our cardiology fellowship that included a comprehensive collection of relevant literature and clinical guides.  It has now moved to OHSU's Bridge site!  It is called the KCVI Cardiovascular Medicine Fellowship at  https://bridge.ohsu.edu/research/kcvi/cardiofellowship/SitePages/Home.aspx (requires login through OHSU portal).  Take a look around.  A personal favorite is the "HF Fellows Hand Out" under Clinical Resources --> OHSU Heart Failure.

This link can also be found through IMRESPDX --> Educational Resources --> Cardiology --> Helpful Sites and Calculators.

Anaphylaxis Pearls

5 Pearls on Anapylaxis Learned at Noon Conference from Dr. Montanaro

1. Mild forms of anaphylaxis include symptoms of itching, nasal congestion, and metallic taste.

2. Skin testing for penicillin allergy is often unreliable, as it only predicts IgE reactions and 50% of patients lose skin testing reactivity after 10 years.

3.  In patients with known NSAID sensitivity, high dose acetaminophen (>3g) may cross-react (cox mechanism)

4. Was your patient stung by an Apid (honey bee) or a Vespid (yellow jacket/wasp/hornet)?  Honey bees leave their venom sac behind after stinging, which should be scraped off rather than rubbed into the skin.

5. Concern for anaphylaxis? Order a tryptase within 48 hours of an anaphylaxis event.  Concern for system mastocytosis or mast cell activation syndrome? Order a tryptase anytime.

Delirium

 Take-away slide: Principles of Delirium Management

Take-away slide: Principles of Delirium Management

  • 3D-CAM is a 3 minute delirium assessment tool found to be 95% sensitive and 94% specific for delirium in older hospitalized patients both with and without delirium (Marcantonio et al Ann Int Med 2014).

 

  • Melatonin is now available to be prescribed at the University in geriatric populations.  The geriatrician's suggested starting dose is Melatonin 1mg qHS.

Please see MedHub for the remaining presentation material and handouts!

Acute Pancreatitis

 Cullen's sign, ecchymosis in the subcutaneous fat around the umbilicus, which isassociated with Grey-Turner's sign (bruising on the flanks). This can indicate pancreatic necrosis with retroperitoneal bleeding.

Cullen's sign, ecchymosis in the subcutaneous fat around the umbilicus, which isassociated with Grey-Turner's sign (bruising on the flanks). This can indicate pancreatic necrosis with retroperitoneal bleeding.

Learning points from conference today:

1) Identifying patients who are at high risk for severe disease is important as this group will require close monitoring and possible intervention. Rather than using one of the scores requiring data at 48 hours (such as Ranson's criteria and the APACHE II score), consider using the "Bedside Index of Severity in Acute Pancreatitis" (BISAP) score in the first 24 hours from this 2008 study published in Gut. The criteria used are:

  • BUN > 25 mg/dL
  • Altered mental status
  • SIRS
  • Age > 60
  • Pleural effusion

More than 2 points = 7 fold risk of organ failure and 10 fold increase in risk of death. Please note the first letters somewhat follow the name of the tool, which makes it easier to remember.

2)  Early nutrition is good and enteral is better than parenteral. A 2004 BMJ meta-analysis of six randomized trials involving a total of 263 patients demonstrated improved outcomes with enteral nutrition including decreased rates of infection and surgical intervention, reduced length of hospital stay, and reduced costs (20 percent of the costs associated with total parenteral nutrition).

Risk Stratification in CAD

 Courtesy Dr. Johnathan Lindner

Courtesy Dr. Johnathan Lindner

The decision to perform exercise or pharmacologic stress testing or coronary CT angiography is based on the patient's:

    pretest likelihood of CAD

    baseline ECG

    ability to exercise

    comorbid illnesses that limit pharmacologic testing

Stress testing is most useful in patients at intermediate pretest likelihood of CAD (10% to 90%).

    In patients with low pretest probability, a normal test result only confirms that the patient is low risk (an abnormal stress test result is most likely a false-positive).

    In patients with a high pretest likelihood, the use of stress testing for diagnostic purposes is not indicated (an abnormal result confirms the presence of disease and a normal result likely to indicate a false-negative). 

Contraindications and Situations Where Use Is Not Advised

    All Forms of Stress: Active ischemic CP, ACS, Recent STEMI, DecompensatedCHF, Aortic dissection, Severe arrhythmias

    Exercise: Inability to exercise, poor conditioning, instability, claudication, COPD, Myocarditis, pericarditis

    Dobutamine; Severe hypertrophy or HOCM, Severe ventricular arrhythmias, severe hypertension

    Dipyridamole/Adenosine: Reactive airways dz, Wheezing, Hypotension (SBP<95), Advanced AV block, Allergy, Recent caffeine

 

Stasis and urticaria and DRESS, oh my!

 Urticaria

Urticaria

Learning Points from "Dermatology for the Internist" conference today:

1. Stasis dermatitis is frequently confused with cellulitis. Cardinal signs of cellulitis are erythema, pain, warmth, and swelling; associated lymphadenopathy or systemic symptoms like fever/chills and malaise may be present. It is unlikely for cellulitis to present on both legs simultaneously. Compared with cellulitis, the redness on the anterior shins in patients with stasis dermatitis is often bilateral and warm to the touch but typically is not tender. Often patients have a history of lower extremity edema. The standard of treatment for stasis dermatitis is compression stockings to help to increase the venous return, decrease the stretching of the skin, and reduce the risk of ulceration.

2. Urticaria (hives) are localized areas of evanescent annular or polycyclic edema associated with pruritus caused by mast cell degranulation and release of inflammatory proteins. Each individual area of edema characteristically lasts less than 24 hours, often flaring in one area while resolving in another, giving the perception that they are “moving around.” The most common causes of urticaria are infections (viral, bacterial, parasitic) and medications such as NSAIDs, aspirin, and intravenous contrast. So, a good recent med history is crucial in understanding the etiology. Antihistamines are the hallmark of treatment providing no angioedema is present or evidence of anaphylaxis.

3. DRESS: Drug hypersensitivity syndrome (DHS) or previously DRESS, drug reaction with eosinophilia and systemic symptoms is a severe, life-threatening, idiosyncratic medication reaction with onset 2-6 weeks after starting a new med (most common culprit medications include sulfa antibiotics, allopurinol, and anticonvulsants).  Skin findings include an exuberant morbilliform eruption with prominent facial edema, lymphadenopathy, and fever.  Important workup includes detecting organ involvement: CBC with diff, liver set, creatinine, UA, and TSH should be performed. Echo should be considered give the potential for DRESS-associated myocarditis. Cornerstone of therapy is to stop the causative medication immediately. Systemic glucocorticoids are typically needed, tapered slowly over multiple weeks to months.

 

Chest Pain

1. What are peaked T waves?
Peaked T waves typically come from hyperkalemia, either local (from myocyte death, i.e. myocardial infarction) or systemic (elevated serum K for whatever reason) and are defined as abnormally symmetric T waves (usual T wave has gradual upslope and brisk downstroke)that are tall (>10mm in precordial leads, >5mm in limb leads, or abnormally tall compared to prior) with a sharp peak.


2. What are balloon pumps and are they helpful?
Balloon pumps are positioned in the descending thoracic aorta and inflates during diastole. They do two things: 1) augment diastolic pressure (increasing coronary perfusion pressure) and 2) afterload reduction (easing myocardial work and reducing wall tension). They have not been extensively studied due to the inherently ill patient population, and there is conflicting evidence for support of their use. They're mainly indicated in high risk PCI and shock due to MI. In high risk PCI there is evidence to suggest benefit in mortality over time (see the BCIS-1 trial). In cardiogenic shock, there is evidence to suggest no benefit (see the IABP-SHOCK II trial), but this trial has been criticized due to heterogenous patient population (see Am J Cardiol 2016; 117(3): 469-76.).