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BACKGROUND Because of concerns for propagating clots into pulmonary emboli by the placement of pneumatic compression boots (PCBs), the standard of care at our institution was to perform a duplex Doppler ultrasound with compression (DUSC) before applying PCBs. We sought to determine the rate of asymptomatic preexisting deep vein thrombosis (DVT) in hospitalized patients who underwent DUSC before PCB. METHODS We evaluated consecutive patients who underwent lower extremity DUSC within 48 hours of admission. All patients were assessed for DVT risk factors using the American College of Chest Physicians' criteria (American College of Chest Physicians Conference on Antithrombotic/Thrombolytic Therapy: Evidence-Based Guidelines, 9th Edition). A t test, Wilcoxon rank sum test, and χ2 or Fisher exact test were used to compare patients characteristics according to DVT status. Logistic regression was used to determine the importance of each risk factor on the risk of DVT. RESULTS DUSC was performed during 1136 hospitalizations; 1071 patients were included in the dataset. Of those, 19 patients (1.8%) had asymptomatic DVT and had at least 1 risk factor; 16 (84.2%) had more than 1 risk factor. The only risk factors that were statistically significant were ambulatory dysfunction and thromboembolic disease history. CONCLUSION Few patients have asymptomatic DVT upon admission; all of these patients have at least 1 predisposing risk factor. There appears to be no need for DUSC prior to initiation of PCBs. DUSC evaluation for DVT may be of value if there is a history of previous DVT, ambulatory dysfunction, or more than 3 risk factors, as the information may change therapeutic approaches. Journal of Hospital Medicine 2014;9:19–22. © 2013 Society of Hospital Medicine

Background Our goal was to define the prevalence of radiation-induced valvular heart (RIVD) disease among patients undergoing cardiac valve surgery in a community-based, regional academic medical center. Mediastinal radiation is a treatment modality for various hematologic and solid malignancies; however, long-term cardiac complications, including radiation-induced valvular heart disease, can occur years after the radiation treatments. Hypothesis Mediastinal radiation exposure is an independent risk factor for valvular heart disease often necessitating valve replacement in patients without other risk factors for valve disease. Methods Between January 1, 1998 and September 1, 2007, we retrospectively analyzed our institution's cardiac surgical database over a 10 year period and identified 189 consecutive patients ≤ 50 years of age who underwent valve surgery. Using case-control matching, we assessed the prevalence of mediastinal radiation among these young patients with valve disease necessitating surgery and to their matched controls from all patients admitted to the hospital. Results Nine individuals (4.8%) were identified as having received previous mediastinal radiation, significantly increased from controls (p

This 12-month longitudinal prospective study tracked the depression and anxiety levels of implantable cardioverter defibrillator recipients after implantation of the device. Depression and anxiety levels dropped significantly over time. These findings suggest that interventions should be implemented early because the needs are greatest in the first few weeks after device implantation.

Hypertensive (HTN) animal models demonstrate lower venous compliance as well as increased venous tone and responsiveness compared with normotensive (NTN) controls. However, the extent to which findings in experimental animals can be extended to humans is unknown. Forearm and calf venous compliance were quantified in 9 NTN (23 ± 1 yr) and 9 HTN (24 ± 1 yr) men at baseline, after administration of nitroglycerin (NTG), during a cold pressor test (CP), and post-handgrip exercise ischemia (PEI). Individual pressure-volume relationships from a cuff deflation protocol (1 mmHg/s) were modeled with a quadratic regression. Regression parameters β1 and β2 were used to calculate compliance. A one-way ANOVA was used to compare the beta parameters and a repeated-measures ANOVA was used to compare volumes across all pressures (between groups at baseline and within groups during perturbations). Limb venous compliance was similar between groups (forearm: NTN β1 = 0.11 ± 0.01 and β2 = −0.00097 ± 0.0001, HTN β1 = 0.10 ± 0.01 and β2 = −0.00088 ± 0.0001; calf: NTN β1 = 0.12 ± 0.01 and β2 = −0.00102 ± 0.0001, HTN β1 = 0.11 ± 0.01 and β2 = −0.00090 ± 0.0001). However, at baseline, volume across all pressures (i.e., capacitance) was lower in the forearm ( P ≤ 0.01) and tended to be lower in the calf ( P = 0.08) in HTN subjects. Venous compliance was not altered by any perturbation in either group. Forearm volume was increased during NTG in HTN subjects only. While venous compliance was similar between NTN and HTN adults, HTN adults have lower forearm venous capacitance (volume) which is increased with NTG. These data suggest that young HTN adults may have augmented venous smooth muscle tone compared with NTN controls.

Venous compliance is lower in older adults compared with younger adults. It is possible that alterations in venous smooth muscle tone and responsiveness may contribute to the age-related differences in venous compliance. To determine the effects of sympathetic activation [cold pressor test (cold pressor test); rhythmic ischemic handgrip (rhythmic ischemic handgrip)] and endothelium-independent decreases in smooth muscle tone [sublingual nitroglycerin (nitroglycerin)] on venous compliance in young and older adults, forearm and calf venous compliance was measured in 12 young (22 ± 1 yr) and 12 old (65 ± 1 yr) supine subjects using venous occlusion plethysmography. Venous compliance was assessed at baseline, during the cold pressor test and rhythmic ischemic handgrip tests, and after nitroglycerin administration. All pressure-volume relationships were modeled with a quadratic regression equation, and β1 and β2 were used as indexes of venous compliance. A repeated-measures ANOVA was used to determine the effect of the age and trial on venous compliance. Calf regression parameters β1 (0.0639 ± 0.0126 vs. 0.0503 ± 0.0059, young vs. older; P < 0.05) and β2 (−0.00054 ± 0.00011 vs. −0.00041 ± 0.00005, young vs. older; P < 0.05) were significantly less in older adults at baseline. Similarly, forearm regression parameters, β1 and β2 were lower in older adults at baseline. Venous compliance was not effected by the cold pressor test test, rhythmic ischemic handgrip, or sublingual nitroglycerin in either group. Data suggest that forearm and calf venous compliance is lower in older adults compared with young. However, this difference probably cannot be explained by alterations in smooth muscle tone or responsiveness.

OBJECTIVE Patients with a low risk of coronary artery disease (CAD) presenting to the emergency department (ED) with chest pain pose a diagnostic dilemma because a small percentage will suffer an acute myocardial infarction (MI) and sudden death. The authors conducted this study to determine whether exercise stress echocardiography (ESE) could be used to further support the safe discharge of these low-risk patients. METHODS A convenience sample of patients > or =30 years of age without a prior cardiac history who presented to an academic community hospital with chest pain, normal initial creatine kinase, and electrocardiography without ischemic changes underwent ESE within 6 +/- 1.7 hours (mean +/- SD). Abnormal ESE was defined as regional wall motion abnormality at rest or after exercise. The ED disposition and three- and six-month follow-up for cardiac events were recorded. This was a prospective observational cohort study. RESULTS Of a total of 149 eligible patients, 145 completed the study. The mean age (+/-SD) was 47 +/- 9 years; 56% were male. No adverse events were noted during ESE. Seven patients (5%) had abnormal ESE (2 with rest wall motion abnormalities and 5 with exercise-induced wall motion abnormalities). Five of the seven underwent cardiac catheterization; three had CAD. All patients received telephone follow-up at three months and six months. Of the 138 patients with a normal ESE, all were free of cardiac events at three months. One patient had a non-Q-wave MI at six months (negative predictive value = 99.3%, 95% CI = 97.8% to 100%). CONCLUSIONS Exercise stress echocardiography can be used to evaluate low-risk chest pain patients in the ED. Patients with a normal ESE may be considered for discharge with minimal risk of sequelae.

Because of concerns for propagating clots into pulmonary emboli by the placement of pneumatic compression boots (PCBs), the standard of care at our institution was to perform a duplex Doppler ultrasound with compression (DUSC) before applying PCBs. We sought to determine the rate of asymptomatic preexisting deep vein thrombosis (DVT) in hospitalized patients who underwent DUSC before PCB.We evaluated consecutive patients who underwent lower extremity DUSC within 48 hours of admission. All patients were assessed for DVT risk factors using the American College of Chest Physicians' criteria (American College of Chest Physicians Conference on Antithrombotic/Thrombolytic Therapy: Evidence-Based Guidelines, 9th Edition). A t test, Wilcoxon rank sum test, and χ(2) or Fisher exact test were used to compare patients characteristics according to DVT status. Logistic regression was used to determine the importance of each risk factor on the risk of DVT.DUSC was performed during 1136 hospitalizations; 1071 patients were included in the dataset. Of those, 19 patients (1.8%) had asymptomatic DVT and had at least 1 risk factor; 16 (84.2%) had more than 1 risk factor. The only risk factors that were statistically significant were ambulatory dysfunction and thromboembolic disease history.Few patients have asymptomatic DVT upon admission; all of these patients have at least 1 predisposing risk factor. There appears to be no need for DUSC prior to initiation of PCBs. DUSC evaluation for DVT may be of value if there is a history of previous DVT, ambulatory dysfunction, or more than 3 risk factors, as the information may change therapeutic approaches.

Current evidence suggests prolonged hospitalization for Acute Coronary Syndrome (ACS) in the setting of chronic kidney disease (CKD). What remains unclear is the impact of CKD on 30-day readmission rate for suspected ACS. All patients who came to the emergency department (ED) from 2004 to 2010 and

BACKGROUND: Our goal was to define the prevalence of radiation‐induced valvular heart (RIVD) disease among patients undergoing cardiac valve surgery in a community‐based, regional academic medical center. Mediastinal radiation is a treatment modality for various hematologic and solid malignancies; however, long‐term cardiac complications, including radiation‐induced valvular heart disease, can occur years after the radiation treatments. HYPOTHESIS: Mediastinal radiation exposure is an independent risk factor for valvular heart disease often necessitating valve replacement in patients without other risk factors for valve disease. METHODS: Between January 1, 1998 and September 1, 2007, we retrospectively analyzed our institution's cardiac surgical database over a 10 year period and identified 189 consecutive patients ≤ 50 years of age who underwent valve surgery. Using case‐control matching, we assessed the prevalence of mediastinal radiation among these young patients with valve disease necessitating surgery and to their matched controls from all patients admitted to the hospital. RESULTS: Nine individuals (4.8%) were identified as having received previous mediastinal radiation, significantly increased from controls (p

Purpose: Primary percutaneous coronary intervention (PCI) is a time-sensitive process. In high risk populations this time could be longer and affect the reperfusion results. The aim of this study was to examine the door-to-balloon time in patients with chronic kidney disease (CKD) and determine the influence of CKD at each step leading to PCI. Methods: We conducted a retrospective study of patients admitted at an academic medical center for suspicion of acute coronary syndrome from 2004 to 2011. ICD9 codes were used to identify patients with myocardial infarction (MI) and comorbidities. CKD was defined using an estimated glomerular filtration rate (GFR) 2 . ST segment elevation (STEMI) status was ascertained at hospital admission. In our hospital, date-times of each step (diagnostic ECG, alert for potential MI) are monitored. Non-parametric tests were used to compare time intervals according to GFR. Because the door-to-balloon time is right skewed, we log transformed time and modeled it as gamma distributed using a generalized estimating equation (GEE) to examine its association with CKD, after adjusting for age, gender, race, hypertension, congestive heart failure, and diabetes. Results: Our study population included 712 patients with STEMI, of whom 138 (19.4%) had CKD (see table). Door-to-balloon time was longer in patients with GFR Conclusion: Patients with severe CKD have a longer door-to-balloon time than patients without CKD. This difference seems to be due to a longer time-interval between the time the diagnostic ECG is made and the time the MI alert is called. This delay in initiating PCI could be related to the misleading ECG (left ventricular hypertrophy, electrolyte and conduction abnormalities) frequently found in patients with CKD.

According to the Joint ESC/ACC/AHA/WHF Task Force, Tn is the preferred biomarker for the diagnosis of acute MI. However, it is still common practice to order both serial CKMB and Tn to rule out acute MI. Our hypothesis is that most clinicians only use Tn and not CKMB in further management decisions

BACKGROUND According to Joint ESC/ACC/AHA/WHF Task Force, troponin I (Tn) is the preferred biomarker for the diagnosis of acute MI. However, it is still common practice to order both serial CKMB and serial Tn to rule out acute MI. OBJECTIVE Our hypothesis is that most clinicians only use Tn and not the CKMB results in the diagnosis of acute MI when both test results are available. Subsequent investigation and management decisions are based on Tn and not on CKMB. METHODS Our large regional academic medical center has about 150,000 ED visits /yr. We queried the electronic medical records of 65,950 patients from Jan 1, 2005 to Dec 31, 2010 who had a Tn within 4 hours of arrival in the ED and at least 2 sets of Tn and CKMB within 24 hours. Out of that cohort we selected the records of 9605 consecutive patients with symptoms suggestive of ACS , admitted to our Clinical Decision Unit, with the express purpose of ruling out acute MI, and then going on to further management pathways based on their initial course. All these patients had both serial Tn and CKMB. These patients were then divided into Group 1 ( 9204 patients- normal serial Tn and CKMB) :mean age 57.33 years, males 45.22%, Caucasian 72.11%, African-American 22.38% and Group 2 (401 patients- normal serial Tn and elevated CKMB ): mean age 58.33 years, males 72.82%, Caucasian 67.58%, African- American 27.43%. RESULTS (See Table) Chi square analysis was used to demonstrate that there was no statistically significant difference between the two groups in the percentage of patients who proceeded to stress test or were discharged without a stress test or a cath. Also, there was no statistically significant difference between the two groups in the percentage of patients who proceeded to cath. CONCLUSIONS In our patient population, elevated CKMB in the absence of elevated troponin did not influence further management decisions. TABLE . TROPONIN NORMAL/CKMB NORMAL TROPONIN NORMAL/ CKMB ELEVATED P VALUE Total patients(9605) 9204 (96.2%) 401 (3.8 %) STRESS TEST 5899 (64.09%) 251 (62.59%) 0.5406 DISCHARGED WITHOUT STRESS TEST OR CATH 2315 (25.15%) 102 (25.44%) 0.8972 CATH WITHOUT STRESS TEST 990 (10.76%) 48 (11.97%) 0.4434

Background: Women with STEMI have increased cardiovascular morbidity and mortality possibly due to pre-treatment delay and atypical presentation. In an effort to decrease door to balloon time (D2B),starting 7/2009, a new strategy was implemented in our institution including10 min door to ECG time, 5 min call back by interventional cardiologist, only interventional cardiologist making the decision for PCI and a goal D2B of ≤60 min with real time tracking. With this strategy, the D2B was significantly shortened. We wanted to see what effect this had on the D2B for female patients. Methods: We studied the records of 393 consecutive STEMI patients who underwent primary PCI in our institution. Four patients were excluded because ECG or decision time were not clearly documented. Group 1 included patients before the new strategy (7/2008-6/2009), and Group 2 after the new strategy (7/2009-6/2010). D2B were further partitioned into 3 segments:door to ECG time (D2ECG), ECG to decision time (ECG2Dec) and decision to balloon time (Dec2B) . Time intervals were compared for both genders within and between these groups. Results: The total D2B decreased with the new strategy from 91.1 min to 80.0 min (p=0.04). In males, neither total D2B nor any time interval decreased significantly. In females, the Dec2B shortened by 6.6 min (p=0.01, Table 1). Before the implementation of the new strategy, the total D2B, D2ECG and Dec2B were all significantly longer in females than in males. After 7/2009, the gender difference in D2B and all time intervals disappeared (Table 2). Conclusion: Implementation of rapid revascularization strategy in our hospital appeared to eliminate the gender difference in D2B. Comparison of time intervals between two groups Group 1 (Nf=58, N m =140) Group 2(Nf=69, N m =122) P value D2B Female 105.6±61.9 86.4±56.0 0.07 Male 85.0±46.7 76.3±52.7 0.16 Door to ECG Female 14.3±18.0 9.9±11.0 0.10 Male 9.1±10.2 9.0±11.6 0.94 ECG to Decision Female 33.8±53.8 25.6±44.3 0.35 Male 22.9±41.2 17.3±41.7 0.27 Decision to Balloon Female 57.6±12.7 51.0±15.4 0.01 Male 53.0±13.7 50.0±15.4 0.10 Data are means ± SD (min). AVONA or t-test were used where appropriate. Nf denotes number of females and Nm denotes males.P values are comparisons between group 1 and group 2 Comparison of time intervals between genders Female(N 1 =58, N 2 =69) Male (N 1 =140, N 2 =122) P value D2B Group 1 105.6±61.9 85.0±46.7 0.018 Group 2 86.4±56.0 76.3±52.7 0.21 Door to ECG Group 1 14.3±18.0 9.1±10.2 0.012 Group 2 9.9±11.0 9.0±11.6 0.61 ECG to Decision Group 1 33.8±53.8 22.9±41.2 0.13 Group 2 25.6±44.3 17.3±41.7 0.20 Decision to Balloon Group 1 57.6±12.7 53.0±13.7 0.029 Group 2 51.0±15.4 50.0±15.4 0.69 Data are means ± SD (min). AVONA or t-test were used where appropriate. N1 denotes number of patients in group1 and N2 denotes group 2.P values are comparisons between females and males.

Prediction of outcomes in ST-elevation myocardial infarction with cardiac arrest often presents difficult clinical decision making. Using the observed results from our institution's data, we introduce a customized, computer-based decision support tool to assist in evaluating and predicting outcomes in such situations. We conclude that this tool can be beneficial to clinicians in decision making or triage of this condition.

Introduction : The purpose of this study is to determine the degree of gender differences in lay person recognition, emergency medical services (EMS) activation, and the prehospital management of STEMI. Methods : Data were gathered prospectively from May 1999 to January 2007 on consecutive patients with STEMI who presented to a tertiary care hospital emergency department. Patients arriving by ambulance and private vehicle were included. Data collection included determining symptom duration, whether a prehospital ECG was obtained, whether the cardiac interventional lab was activated prior to patient arrival at the hospital, patient age, and hospital length of stay. Prehospital activation of the cath lab was done by emergency medicine based on paramedic ECG interpretation in consultation with cardiology. Statistical analysis was performed using the Mann-Whitney U test, the Yates-corrected chi-square test, and linear regression. Results : A total of 3260 cases were studied, of which, 3097 had complete data for analysis. Only EMS cases were included in the ECG analysis, and only patients having a prehospital ECG were included in the prehospital activation of cath lab analysis. Regression analysis showed that older age and female gender were significant predictors of access and arrival by EMS. The mean age in years was higher for EMS arrival (69 women; 59 men) than for private vehicle (62 women; 56 men). Conclusion : Women with STEMI tend to use EMS more frequently then men, but are older and wait longer before seeking treatment. Whether these factors contribute to the longer length of stay remains to be determined.

Methods: We examined records of 2290 consecutive patients at our institution suspected of having ST-Elevation myocardial infarction (STEMI) from 1/1/02 to 12/31/06. Our study group comprised 99 STEMI patients resuscitated from cardiac arrest who were taken for emergent catheterization. Percutaneous coronary intervention was performed in 66, bypass surgery in 12, and 21 have neither. Endpoints were in-hospital death and neurologic recovery. Logistic regression was used for analysis. Results: Overall 64 (65%) survived and 35 (35%) died. Full neurologic recovery was seen in 59 (92%) of the survivors. On evaluation before catheterization: 25 were alert , 14 were minimally responsive to pain and stimuli, 60 were unresponsive . Patients in the latter two groups were intubated. In the unresponsive group (n=60), 27 survived (45%) and 33 died. Full neurologic recovery was seen in 23/27 survivors (85%). Predictors of death and neurologic recovery are shown in Table 1 and Table 2 . Table 1: Logistic Regression for Death For the Entire Group (c index = 0.894), N= 99 Table 2: Logistic Regression for Death for the Unresponsive Group (c index = 0.898), N=60

To the Editor: Left main coronary artery (LMCA) vasospasm induced by angiographic catheters during coronary angiography, although uncommon, is a recognized complication of this procedure ([1,2][1]). However, the inability to distinguish vasospasm from obstructive disease of the LMCA can lead to

To determine whether a diet of high saturated fat and avoidance of starch (HSF-SA) results in weight loss without adverse effects on serum lipids in obese nondiabetic patients.Twenty-three patients with atherosclerotic cardiovascular disease participated in a prospective 6-week trial at the Christiana Care Medical Center in Newark, Del, between August 2000 and September 2001. All patients were obese (mean +/- SD body mass index [BMI], 39.0+/-7.3 kg/m2) and had been treated with statins before entry in the trial. Fifteen obese patients with polycystic ovary syndrome (BMI, 36.1+/-9.7 kg/m2) and 8 obese patients with reactive hypoglycemia (BMI, 46.8+/-10 kg/m2) were monitored during an HSF-SA diet for 24 and 52 weeks, respectively, between 1997 and 2000.In patients with atherosclerotic cardiovascular disease, mean +/- SD total body weight (TBW) decreased 5.2%+/-2.5% (P.001) as did body fat percentage (P=.02). Nuclear magnetic resonance spectroscopic analysis of lipids showed decreases in total triglycerides (P.001), very low-density lipoprotein (VLDL) triglycerides (P.001), VLDL size (P.001), large VLDL concentration (P.001), and medium VLDL concentration (P.001). High-density lipoprotein (HDL) and LDL concentrations were unchanged, but HDL size (P=.01) and LDL size (P=.02) increased. Patients with polycystic ovary syndrome lost 14.3%+/-20.3% of TBW (P=.008) and patients with reactive hypoglycemia lost 19.9%+/-8.7% of TBW (P.001) at 24 and 52 weeks, respectively, without adverse effects on serum lipids.An HSF-SA diet results in weight loss after 6 weeks without adverse effects on serum lipid levels verified by nuclear magnetic resonance, and further weight loss with a lipid-neutral effect may persist for up to 52 weeks.

Objectives We examined outcomes of patients resuscitated from cardiac arrest owing to ST-segment elevation myocardial infarction (STEMI) and predictors of survival and neurologic recovery. Background Immediately after resuscitation from cardiac arrest owing to STEMI, many patients show signs of neurologic impairment, and benefits of percutaneous coronary intervention and subsequent prognosis are not well defined. Methods Between January 1, 2002, and December 31, 2006, we retrospectively identified consecutive patients resuscitated from cardiac arrest, regardless of time to return of spontaneous circulation (ROSC) and neurologic status, and reviewed the outcomes of those who had STEMI. Mortality and neurologic recovery at discharge and long-term mortality were assessed by individual chart review for those who underwent emergent angiography. Results Our study population consisted of 98 patients; 64% survived to discharge, and 92% had a full neurologic recovery. Predictors of survival were shorter time to ROSC, younger age, neurologic status post-resuscitation (alert or minimally responsive), and male sex. Predictors of neurologic recovery included shorter time to ROSC, neurologic status post-resuscitation (alert or minimally responsive), and younger age. Ninety-six percent of patients who were alert post-resuscitation survived. Ninety-three percent of patients who were minimally responsive post-resuscitation survived. Fifty-nine patients were unresponsive post-resuscitation, with 44% survival, of whom 88% had full neurologic recovery. In the unresponsive group, unwitnessed arrest, prolonged ROSC, and older age were associated with increased risk of death, and older age and prolonged ROSC predicted poor neurologic recovery. Conclusions When resuscitated patients with STEMI are being evaluated in the emergency department, serious consideration should be given to emergent angiography and revascularization, regardless of neurologic status.

The optimal timing of surgery for asymptomatic severe mitral regurgitation (MR) remains debatable. Excessive TGF-b activation is known to lead to pathological remodeling of the ventricular myocardium. Myocardial tissue and blood samples were collected from patients with severe MR undergoing mitral

Prevalence and outcomes of patients who are on chronic Vitamin K antagonist therapy (VKA) in acute STEMI populations are largely unknown as they were excluded from prospective clinical trials. It is unclear whether chronic VKA is associated with increased longterm mortality. In a large academic