IntroductionSeveral studies have shown that workplace violence in the emergency department (ED) is common. Residents may be among the most vulnerable staff, as they have the least experience with these volatile encounters. The goal for this study was to quantify and describe acts of violence against emergency medicine (EM) residents by patients and visitors and to identify perceived barriers to safety.MethodsThis cross-sectional survey study queried EM residents at multiple New York City hospitals. The primary outcome was the incidence of violence experienced by residents while working in the ED. The secondary outcomes were the subtypes of violence experienced by residents, as well as the perceived barriers to safety while at work.ResultsA majority of residents (66%, 78/119) reported experiencing at least one act of physical violence during an ED shift. Nearly all residents (97%, 115/119) experienced verbal harassment, 78% (93/119) had experienced verbal threats, and 52% (62/119) reported sexual harassment. Almost a quarter of residents felt safe “Occasionally,” “Seldom” or “Never” while at work. Patient-based factors most commonly cited as contributory to violence included substance use and psychiatric disease.ConclusionSelf-reported violence against EM residents appears to be a significant problem. Incidence of violence and patient risk factors are similar to what has been found previously for other ED staff. Understanding the prevalence of workplace violence as well as the related systems, environmental, and patient-based factors is essential for future prevention efforts.

Since their discovery in the 1980s, angiotensin-converting enzyme (ACE) inhibitors have been shown to decrease angiotensin formation, prevent breakdown of bradykinin, and may also act on peptides of the renin-angiotensin system. They are effective in reducing the risk of heart failure, myocardial infarction, and death from cardiovascular causes in patients with left ventricular systolic dysfunction or heart failure, and have been shown to reduce atherosclerotic complications in patients who have vascular disease without heart failure. They may preserve endothelial function and counteract initiation and progression of atherosclerosis. Broadly, ACE inhibitors can be divided into tissue specific or serum ACE inhibitors. Tissue-specific ACE inhibitors as a group are not superior to serum ACE inhibitors in the treatment of coronary artery disease. Pending direct comparator clinical trials between a tissue ACE inhibitor and a plasma ACE inhibitor, both ramipril and perindopril can be recommended for secondary risk prevention, based on the evidence.

Cumulative evidence supports the use of angiotensin-converting enzyme (ACE) inhibitors for stable coronary artery disease in patients with and without heart failure. The dose and unique properties of ACE inhibitors, trial data, differences in trial design and demographics, may all contribute to variable responses in clinical outcomes. Pending direct comparator clinical trials between a tissue ACE inhibitor vs a plasma ACE inhibitor, evidence indicates that both ramipril and perindopril can be recommended for secondary risk prevention.

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A 63-year-old male is admitted to the CCU for chest pain, shortness of breath, and an elevated troponin.The patient is a 63-year-old male with a past medical history significant for hypertension and hypercholesterolemia who presented to the emergency room with a chief complaint of shortness of breath and chest pain. The chest pain began two days prior and was associated with nausea. The patient proceeded to have increasing shortness of breath over the subsequent two days which brought him to the emergency room for evaluation.In the emergency room, the patient was noted to be in atrial fibrillation with rapid ventricular response and hypotension. He was cardioverted into sinus rhythm. The ECG showed sinus rhythm, RBBB and inferior myocardial infarction age indeterminate. The cardiac enzymes drawn in the emergency room showed a troponin of 30 ng/mL. The patient was transferred to the Coronary Care Unit. An echocardiogram performed in the Coronary Care Unit demonstrated a ventriculoseptal defect. The patient was emergently taken to the catheterization lab.The right heart catheterization demonstrated a mean right atrial pressure of 18 mmHg, right ventricular pressure of 42/18 mmHg, pulmonary pressure of 40/24 mmHg, and a pulmonary capillary wedge pressure of 23 mmHg. The right atrial oxygen saturation was 31% and the right ventricular oxygen saturation was 81%.The left ventriculogram demonstrated severe anterolateral hypokinesis and apical hypokinesis. There was evidence of dye exstravasation just superior to the anterolateral segment with late filling of the pulmonary artery suggesting a left to right shunt. Coronary arteriography demonstrated a 100% proximal occlusion of the left anterior descending artery after the first diagonal. The left circumflex artery had diffuse disease in the marginal system. The remaining vessels were angiographically normal.The patient was taken emergently to the operating room. Intraoperative transesophageal echocardiogram revealed a large ventricular septal defect in the apical portion of the septum located primarily anteriorly. The patient underwent coronary artery bypass grafting of the left internal mammary to the left anterior descending artery and the left radial artery to the first diagonal artery. The patient also received a bovine pericardial patch repair of the anterior apical VSD.The remainder of his hospital stay was unremarkable and he was discharged, however soon after discharge the patient began to develop progressively worsening shortness of breath requiring readmission to the hospital.Echocardiogram showed a large color flow turbulence moving across the septum consistent with a VSD. This was confirmed by cardiac MRI which showed a VSD between the left ventricle and