Contemporary professional society recommendations for patients presenting to the emergency department with acute chest pain and low clinical risk encourage noninvasive testing for coronary artery disease (CAD) before, or shortly after, discharge from the emergency department. Recent reports indicate that a strategy of universal testing has a low diagnostic yield and may not be necessary. We examined data from a prospective cohort of patients who underwent evaluation of acute chest pain in our chest pain evaluation center (CPEC). Patients presenting with normal initial electrocardiogram and cardiac injury markers were eligible for observation and noninvasive testing for CAD in our CPEC. All patients were asked to participate in the prospective registry. The 213 subjects who consented were young, obese, and predominantly women (mean age 43.8 ± 12.5, mean body mass index of 30.8 ± 7, 64.8% women). Prevalence of diabetes was 10.3% (hypertension 37.1%, hyperlipidemia 17.8%, and current tobacco use 23.5%) Exercise treadmill testing was the primary method of evaluation (n = 104, 49%) followed by computed tomography coronary angiography (n = 58, 27%) and myocardial perfusion imaging (n = 20, 9%). Of 203 patients who underwent testing, 11 had abnormal test results, 4 of whom had obstructive CAD based on invasive coronary angiography. The positive predictive value for obstructive CAD after an abnormal test was 45.5%, and the overall diagnostic yield for obstructive CAD was 2.5%. In conclusion, in patients with acute chest pain evaluated in a CPEC, the yield of routine use of noninvasive testing for CAD was minimal and the positive predictive value of an abnormal test was low.

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A 54-year-old woman with advanced cirrhosis secondary to hepatitis C, end-stage kidney failure on hemodialysis, and nonischemic cardiomyopathy was admitted to the medical intensive care unit for treatment of a superior vena cava (SVC) thrombus involving a recently implanted cardioverter-defibrillator (ICD). During her hospitalization, the patient abruptly developed frequent ventricular ectopy with up to 20 beat runs of hemodynamically significant nonsustained ventricular tachycardia. Because ventricular ectopy was not previously seen in the patient, the sudden onset prompted a thorough evaluation. After other causes were excluded, a recently placed scopolamine patch was removed; the ventricular ectopy completely resolved within 24 hours and did not recur for the remainder of the patient's extended hospitalization. While anticholinergic syndrome is associated with a vagally mediated sinus tachycardia, ventricular arrhythmias have not previously been reported with scopolamine, to the best of the authors' knowledge. The observed cardiac side effects of scopolamine rarely occur at therapeutic doses. Scopolamine is metabolized primarily in the liver and excreted by the kidneys, so renal and hepatic impairment should be considered when initiating and dosing this medication. Because anticholinergic medications including scopolamine are commonly used in various clinical settings, we believe that clinicians should be aware of this significant but completely reversible adverse effect.

Summary Background Approximately 10–20% of myocardial perfusion imaging (MPI) tests are inappropriate based on professional society recommendations. The correlation between inappropriate MPI and quality care metrics is not known. Hypothesis We hypothesize that inappropriate MPI will be associated with low achievement of quality care metrics. Methods We conducted a retrospective cross-sectional investigation at a single Veterans Affairs medical center. MPI ordered by primary care clinicians between December 2010 and July 2011 were assessed for appropriateness (by 2009 criteria). Using documentation of the clinical encounter where the MPI was ordered, we determined how often quality care metrics were achieved. Results Among 516 MPI patients, 52 (10.1%) were inappropriate and 464 (89.9%) were not inappropriate (either appropriate or uncertain). Hypertension (82.2%), diabetes mellitus (41.3%), and coronary artery disease (41.1%) were common. Hemoglobin A1c levels were lower in the inappropriate MPI cohort (6.6% versus 7.5%, p=0.04). No difference was observed in the proportion at goal (62.5% versus 46.3% for appropriate/uncertain, p=0.258). Systolic blood pressure was not different (132 mmHg versus 135 mmHg, p=0.34). Achievement of several other categorical quality metrics was low in both cohorts and no differences were observed. Over 90% of clinicians documented a plan to achieve most metrics. Conclusions Inappropriate MPI is not associated with performance on metrics of quality care. If an association exists, it may be between inappropriate MPI and overly aggressive care. Most clinicians document a plan of care to address failure of quality metrics, suggesting awareness of the problem.

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A 39-year-old woman suffering from migraine took two suppositories of an ergotamine-containing proprietary drug (Cafergot, containing 2 mg ergotamine tartrate) for the first time again after an abstinence of two years. Twenty-four hours later she developed symptoms of decreased peripheral blood flow in all four limbs. Walking distance without pain was reduced to 100 m, but the severest changes affected the right arm, with livid discolorations and complete immobility 16 hours after the onset of symptoms. Despite administration of morphine derivatives the pain progressively increased. Angiography demonstrated spastic narrowing of all arm arteries below the axillary artery. No vessels were visualized below the lower-arm bifurcation. Thereupon 4 mg nifedipine were injected through the angio-catheter within 30 min (five individual doses of 0.8 mg each). This was followed by intravenous infusion of 0.5 mg/h. The pain immediately decreased and the livid discoloration as well as impaired arm movement improved. A residual deficit, incomplete lesion of the median nerve, persisted but gradually regressed during the following two months.

2016-11-03T14:11:40

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