Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond.
Albuminuria is common and is associated with increased risk for adverse outcome in patients with ACHD with biventricular circulation. Albuminuria appears especially useful in stratifying risk in patients categorized as NYHA functional class 2.
A 55-year-old woman with hypertension presented with sudden onset of severe pressure-like chest pain that started when she was taking a bath. The pain radiated to her back and was associated with nausea. A 12-lead electrocardiogram (Figure 1) showed ST-segment elevation of more than 2 mm in leads V 2 , V 3 , V 4 , and V 5 , with no reciprocal changes. In view of her ongoing severe chest pain, she was given aspirin and ticagrelor and was taken for emergency cardiac catheterization. Left ventriculography showed hypokinesis in the mid-anterior, distal anterior, apical, and distal inferior chamber walls. Coronary angiography (Figure 2) revealed a long segment of diffuse, smooth narrowing of the mid-left anterior descending coronary artery that did not reverse after administration of intracoronary nitroglycerin. Based on the classic angiographic appearance and the absence of atherosclerotic disease in other coronary arteries, type 2 spontaneous coronary artery dissection (SCAD) was diagnosed. ■ CORONARY ARTERY WALL SEPARATION SCAD is defined as a nontraumatic, noniatrogenic intramural hemorrhage leading to separation of the coronary arterial wall and the formation of a false lumen. The separation can occur between any of the coronary artery wall layers and may or may not involve an intimal tear. The bleeding may result in an intramural hematoma and possible narrowing of the arterial lumen. Depending on the severity of REVIEW
T h e ne w e ngl a nd jou r na l o f m e dicine n engl j med 374;5 nejm.org February 4, 2016 e5
Images in Clinical MedicineA 58-year-old woman presented to the emergency department with intermittent, nonexertional chest pain of 2 days' duration, with each episode lasting 15 minutes. The pain was relieved by sublingual nitroglycerin and acetaminophen with hydrocodone. Her medical history was notable for tobacco and alcohol use, hypertension, and hyperlipidemia. She had been admitted for similar symptoms 2 months earlier, at which time a coronary angiogram revealed normal coronary anatomy (Video 1). She was discharged home with a diagnosis of pericarditis, and treatment with colchicine and ibuprofen was started. Electrocardiography performed during her more recent visit revealed anterior T-wave inversions (Panel A), which had also been observed during her previous visit. Her initial troponin I level was 0.04 ng per milliliter (reference range, 0 to 0.03 ng per milliliter); it rose to 5.7 ng per milliliter at 6 hours and peaked at 6.4 ng per milliliter before falling to 0.71 ng per milliliter. A transthoracic echocardiogram (Video 2) revealed a pericardial effusion that was small to moderate in size, normal ventricular function, and no abnormalities in wall motion. She was admitted to the hospital with a diagnosis of myopericarditis and was treated with oral glucocorticoids; her symptoms resolved.On hospital day 3, she had a cardiopulmonary arrest (ventricular fibrillation). After she received advanced cardiopulmonary life support for 5 minutes, spontaneous circulation returned. An electrocardiogram obtained after her circulation returned revealed ST-segment elevation of 2 mm in the anteroseptal lead and ST-segment depression of 1 to 2 mm in the lateral and inferior leads (Panel B). Emergency coronary angiography (Video 3) revealed severe coronary spasm involving the left main, left anterior descending, and circumflex arteries (Thrombolysis in Myocardial Infarction [TIMI] flow of 1). The spasm was reversed on administration of intracoronary nitroglycerin (TIMI flow of 3) (Video 4). A urine toxicology test was performed, and the results were positive for cocaine. It appears that this patient used cocaine during hospitalization, which led to active coronary spasm. The patient died from complications of myocardial infarction.
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