RESUMEN
The aim of this study was to investigate whether asymptomatic patients with known coronary artery disease and demonstrable myocardial ischemia warrant revascularization on prognostic grounds. A Medline and PubMed search was performed, including 7 trials with data discussed and concise reviews of prominent articles in the field. The magnitude of inducible ischemia in those with known coronary disease correlates closely with poor cardiovascular outcomes in terms of death, myocardial infarction, hospitalization, and revascularization. Patients with ≥10% inducible ischemia experience a survival advantage when revascularized with a reduction in mortality of greater than 50% regardless of symptoms (P < 0.00001). Evidence also suggests that left ventricular function remains preserved in those who are revascularized when compared with medical therapy alone; left ventricular ejection fraction 53.9% versus 48.8% (P < 0.001). Silent ischemia is a useful prognostic marker in those with known coronary disease. It is recommended that asymptomatic patients with known coronary disease be revascularized on prognostic grounds if ≥10% ischemia can be demonstrated on nuclear or myocardial perfusion scan, ≥3 segments of regional wall motion abnormality on stress echocardiography/cardiac magnetic resonance imaging, or ≥2 segments with perfusion deficits on stress perfusion cardiac magnetic resonance imaging.
Asunto(s)
Enfermedad de la Arteria Coronaria , Isquemia Miocárdica , Revascularización Miocárdica , Enfermedades Asintomáticas , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/etiología , Isquemia Miocárdica/fisiopatología , Isquemia Miocárdica/cirugía , Revascularización Miocárdica/métodos , Revascularización Miocárdica/normas , PronósticoRESUMEN
The latest European Society of Cardiology guideline on the management of acute coronary syndromes without persistent ST-elevation stipulates several acceptable pathways through which patients presenting with chest pain can be assessed for unstable coronary disease. This article reviews the data behind the "rule-in and rule-out algorithm," which can exclude acute myocardial infarction within 1 hour of presentation through the use of fifth generation high-sensitivity troponin assays.
Asunto(s)
Algoritmos , Dolor en el Pecho/diagnóstico , Diagnóstico Precoz , Servicio de Urgencia en Hospital , Infarto del Miocardio/diagnóstico , Triaje/métodos , Troponina/sangre , Biomarcadores/sangre , Dolor en el Pecho/sangre , Dolor en el Pecho/etiología , Electrocardiografía , Humanos , Infarto del Miocardio/sangre , Infarto del Miocardio/complicaciones , Factores de TiempoRESUMEN
Objective: The United States Office of the National Coordinator for Health Information Technology sponsored the development of a "high-priority" list of drug-drug interactions (DDIs) to be used for clinical decision support. We assessed current adoption of this list and current alerting practice for these DDIs with regard to alert implementation (presence or absence of an alert) and display (alert appearance as interruptive or passive). Materials and methods: We conducted evaluations of electronic health records (EHRs) at a convenience sample of health care organizations across the United States using a standardized testing protocol with simulated orders. Results: Evaluations of 19 systems were conducted at 13 sites using 14 different EHRs. Across systems, 69% of the high-priority DDI pairs produced alerts. Implementation and display of the DDI alerts tested varied between systems, even when the same EHR vendor was used. Across the drug pairs evaluated, implementation and display of DDI alerts differed, ranging from 27% (4/15) to 93% (14/15) implementation. Discussion: Currently, there is no standard of care covering which DDI alerts to implement or how to display them to providers. Opportunities to improve DDI alerting include using differential displays based on DDI severity, establishing improved lists of clinically significant DDIs, and thoroughly reviewing organizational implementation decisions regarding DDIs. Conclusion: DDI alerting is clinically important but not standardized. There is significant room for improvement and standardization around evidence-based DDIs.
Asunto(s)
Interacciones Farmacológicas , Registros Electrónicos de Salud/normas , Sistemas de Entrada de Órdenes Médicas/normas , Presentación de Datos , Registros Electrónicos de Salud/estadística & datos numéricos , Humanos , Sistemas de Entrada de Órdenes Médicas/estadística & datos numéricos , Sistemas de Registros Médicos Computarizados , Estados UnidosRESUMEN
OBJECTIVE: To assess the authors' hypothesis that with modern techniques, the current risks of repair for both complete and partial atrioventricular canal (AVC) are equal. SUMMARY BACKGROUND DATA: Repair of complete AVC in infancy has traditionally carried a substantial mortality. In contrast, partial AVC has been considered low-risk for repair and can be performed later in childhood. METHODS: This was a retrospective review of 63 infants and children who underwent complete (n = 40) or partial AVC repair (n = 23) from 1990 to 2001. Among complete AVC patients, the ventriculoseptal defect was repaired via an individualized approach according to each patient's specific anatomy: direct suturing without a patch (n = 5) and/or interposition of a small pericardial patch with a running suture (n = 35). In all 63 patients the left AV valve cleft was closed with interrupted sutures, and all atrial defects were closed with a pericardial patch. Data were analyzed with the Student test and Fisher exact test. RESULTS: Results are expressed as the mean +/- SEM. Age at operation was 6.3 +/- 2.0 months for complete AVC and 47.5 +/- 6.1 months for partial AVC (P <.001). Bypass time was 65.2 +/- 2.3 minutes for complete AVC and 58.3 +/- 3.9 minutes for partial AVC ( P=.1). Reoperation rate was 7.5% (3/40) for complete AVC and 13.0% (3/23) for partial AVC ( P=.6). Early mortality was 2.5% (1/40) for complete AVC and 0% (0/23) for partial AVC ( P=.6). CONCLUSIONS: Compared to partial AVC, patients presenting for complete AVC repair are significantly younger and manifest more complex anatomy and pathophysiology. However, utilizing modern techniques, including an individualized surgical approach to the ventricular component, repair of complete AVC yields reoperation and early mortality rates similar to those of partial AVC.