RESUMEN
Anticoagulation for the pregnant patient with valve disease is problematic: both the underlying thrombotic disorder and the pharmacologic agents available for its treatment pose significant risks to the mother and fetus. There are no randomized controlled trial data available to guide decision-making for this patient population. Clinical treatment algorithms usually are derived from patient registries or case series with the obvious limitations of retrospective review, selection bias, historical controls, and small patient numbers. Prospective trials clearly are needed, but clinical research in the pregnant patient presents a myriad of ethical and legal challenges. Warfarin and unfractionated heparin, the mainstays of anticoagulant therapy, fall quite short in any analysis of efficacy and safety. There is an increasing use of low molecular weight heparins (LMWHs) in clinical practice but without evidence-based validation. Anticoagulant management of the pregnant patient must begin with full disclosure of the hazards and limitations of all forms of available treatments, preferably prior to conception. Treatment should be predicated on an assessment of the relative risks of thrombosis and hemorrhage. Careful monitoring and dosage adjustment are required throughout gestation, labor, delivery, and the puerperium.
RESUMEN
The treatment of patients with acute aortic dissection must begin as soon as the diagnosis is first suspected. Aggressive measures to lower the systemic blood pressure and its rate of increase (dP/dt), usually with intravenous beta-blockade in combination with sodium nitroprusside, should be instituted immediately, even before confirmatory imaging studies are performed. Patients with type A dissection are best managed with emergency surgery, whereas patients with type B dissection should be treated medically unless complications intervene. There is a growing experience with catheter-based techniques, including fenestration, stenting, and endoluminal graft insertion, for the management of selected patients with acute dissection. Regardless of the initial treatment strategy adopted, hospital survivors should continue strict antihypertensive therapy, and a schedule of surveillance imaging studies should be established.
RESUMEN
The objective of this study were to assess the impact of a quality assurance effort on the door-to-needle time and the choice of thrombolytic agent for the management of acute myocardial infarction in the emergency department. The study design involved a prospective collection of data on a series of consecutive patients who received a thrombolytic agent for a presumed acute myocardial infarction. The study was carried out in the emergency department of a major university urban tertiary care center. A total of 349 patients were studied from September 1989 to March 1994. The quality assurance program began in 1989 and included chart review of all patients receiving thrombolytic therapy, with special attention to all patients with door-to-needle times >60 minutes to identify causes for delay. Feedback was directed to pharmacy, nursing, and physician staff. Biannual reports were distributed throughout the hospital and the emergency department. Nursing-specific feedback led to the development of protocols for all aspects of the delivery of thrombolytic agents. The choice of thrombolytic agent was not dictated by the protocol, but the physician staff was continuously updated on the results of the latest clinical trials comparing one thrombolytic agent with another. The mean age was 58 years for men and 67 years for women in this cohort consisting of 78% men and 22% women. Thirty-seven percent of the myocardial infarctions were in an anterior location and 56% were in an inferior location. The median duration of chest pain before presentation to the emergency department was 120 minutes. Hospital mortality was 3%. Median door-to-needle time fell from 46 (1989-1991) to 36 (1992-1994) minutes, P& < 0.01. The percentage of patients with a door-to-needle time >60 minutes decreased from 35% (1989-1991) to 16% (1992-1994) minutes, P < 0.0001. Corresponding with the ISIS-3 report, there was a significant increase in the proportion of patients receiving streptokinase over the first 3 years of the study (P < 0.0001), which changed to a trend toward increased utilization of tissue plasminogen activator with the GUSTO report in the final 6 months of the study. In conclusion, a quality assurance program led to a significant reduction in the door-to-needle time, and recent megatrials were found to influence the choice of thrombolytic agent used.