Listen Before You Auscultate: An Active-Learning Approach to Bedside Cardiac Assessment.

Introduction: Bedside cardiac assessment (BCA) is deficient across a spectrum of noncardiology trainees. Learners not taught BCA well may become instructors who do not teach well, creating a self-perpetuating problem. To improve BCA teaching and learning, we developed a high-quality, patient-centered curriculum for medicine clerkship students that could be flexibly implemented and accessible to other health professions learners. Methods: With a constructivist perspective, we aligned learning goals, activities, and assessments. The curriculum used a "listen before you auscultate" framework, capturing patient history as context for a six-step, systematic approach. In the flipped classroom, short videos and practice questions preceded two 1-hour class activities that integrated diagnostic reasoning, pathophysiology, physical diagnosis, and reflection. Activities included case discussions, jugular venous pressure evaluation, heart sound competitions, and simulated conversations with patients. Two hundred sixty-eight students at four US and international medical schools participated. We incorporated feedback, performed thematic analysis, and assessed learners' confidence and knowledge. Results: Low posttest data capture limited quantitative results. Students reported increased confidence in BCA ability. Knowledge increased in both BCA and control groups. Thematic analysis suggested instructional design strategies were effective and peer encounters, skills practice, and encounters with educators were meaningful. Discussion: The curriculum supported active learning of day-to-day clinical competencies and promoted professional identity formation alongside BCA ability. Feedback and increased confidence on the late-clerkship posttest suggested durable learning. We recommend approaches to confirm this and other elements of knowledge, skill acquisition, or behaviors and are surveying impacts on professional identity formation-related constructs.

Medical emergency kits in ambulatory care clinics.

Implementation and staff perceptions of usability and feasibility.

Takotsubo Cardiomyopathy and Catatonia in the Setting of Benzodiazepine Withdrawal.

We report two serious and unusual complications of benzodiazepine withdrawal in a single patient: takotsubo cardiomyopathy and catatonia. This 61-year-old female patient was brought to the emergency department with lethargy and within hours had declined into a state of catatonia. Although there was never a complaint of chest pain, ECG showed deep anterior T-wave inversions and cardiac enzymes were elevated. An echocardiogram was consistent with takotsubo cardiomyopathy. She later received 1 mg of midazolam and within minutes had resolution of catatonic symptoms. Careful history revealed that she had omitted her daily dose of lorazepam for 3 days prior to admission. To our knowledge, the case presented herein is the first report of simultaneous catatonia and takotsubo cardiomyopathy in the setting of benzodiazepine withdrawal. The pathogenesis of both conditions is poorly understood but may be indirectly related to the sudden decrease in γ-aminobutyric acid (GABA) signaling during benzodiazepine withdrawal.

Effects of cardiology review of the electrocardiogram in patients with suspected acute coronary syndromes.

BACKGROUND: Misclassification of the electrocardiogram (ECG) contributes to treatment errors in patients with acute coronary syndrome. We hypothesized that cardiology ECG review could reduce these errors. OBJECTIVE: The purpose of this study is to examine the effects of real-time cardiology ECG review in patients evaluated for acute coronary syndrome. METHODS: A prospective observational study was done on weekdays, 8 AM to 11 PM, from April 28, 2006, to October 27, 2006, in an urban academic medical center. Eligible subjects were those aged 21 years with chest pain or the equivalent. Those with ECGs considered "normal" or "unchanged from baseline" were excluded. Emergency physicians completed a data sheet and faxed the ECG to a cardiology fellow for review. The primary outcome was the effect of the cardiology review on emergency department (ED) triage and treatment decisions. We excluded those who eloped or left against medical advice (AMA) or those cases wherein the cardiology fellow came to evaluate the patient. Data included demographics, clinical and ECG characteristics, and a 3-month outcome. We used descriptive statistics with 95% confidence intervals. RESULTS: One hundred forty-nine ECGs were faxed to a cardiology fellow. One hundred twenty cases were analyzed. Excluded were AMA/eloped/ineligible (n = 11) and those whose cardiology forms were unavailable (n = 18). Subjects were aged (median) 50.5 years (range, 24-93 years), 50% (n = 60) were female, and 87.5% (n = 105) had cardiac markers in ED. Cardiology ECG review triggered callback in 6 cases (5.0%; 95% confidence interval, 1.5%-10.9%) with documented discussion with a cardiology fellow about treatment. In 3 cases (2.5%; 95% confidence interval, 0.5%-7.1%), disposition was changed to coronary care unit and cardiac catheterization consulted, although none were emergently treated.

Acute anterolateral papillary muscle rupture in the absence of coronary artery disease.

Acute papillary muscle rupture is usually associated with a myocardial infarction and involves the posteromedial muscle. We present a case of spontaneous rupture of the anterolateral papillary muscle due to an isolated infarct of the papillary muscle in the absence of epicardial coronary artery disease.

Pulmonary arterial hypertension and left-sided heart disease in sickle cell disease: clinical characteristics and association with soluble adhesion molecule expression.

Pulmonary hypertension (PH), a risk factor for mortality in sickle cell disease (SCD), has pathologic features of both pulmonary arterial hypertension (PAH) and PH related to left-sided heart disease (LHD) suggesting a link between these two entities. We hypothesized that both are characterized by endothelial dysfunction and increased adhesion molecule expression. SCD patients and normal volunteers underwent a screening questionnaire, echocardiogram, and blood donation for preparation of platelet-poor plasma. PAH was defined as a tricuspid regurgitant jet (TRJ) velocity > or =2.5 m/sec and/or the presence of isolated right ventricular hypertrophy or decreased systolic function. LHD was defined as either left-sided systolic/diastolic dysfunction or significant valvular disease. Plasma vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), P- and E-selectin, nitric oxide (NO(x)), erythropoietin, and vascular endothelial growth factor (VEGF) levels were assayed by enzyme-linked immunoassay. Forty-three percent of sickle cell anemia (HbSS) and 28% of hemoglobin SC disease (HbSC) disease patients had PAH. Additionally, 10-15% of SCD patients had LHD. VCAM-1 levels were significantly increased in HbSS patients compared with HbSC patients and normal volunteers. VCAM-1 and P-selectin levels correlated positively with TRJ velocity in HbSS patients (r = 0.45, P = 0.03, r = 0.2, P = 0.05, respectively). ICAM-1, E-selectin, NO(x), erythropoietin, and VEGF levels were similar across subject groups. PH is common in SCD and, at times, due to LHD. Increased VCAM-1 and P-selectin expression was associated with TRJ elevation regardless of etiology suggesting a similar effect on endothelial gene expression and possibly providing a pathologic link between PAH and PH related to LHD in SCD.

Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: results of an observational study.

The aim of the study were to determine if paramedics can accurately identify ST-segment elevation myocardial infarction (STEMI) on prehospital 12-lead (PHTL) electrocardiogram and to compare paramedic with blinded physician identification of STEMI. Paramedics identified definite STEMI, or possible acute myocardial infarction but not definite, and nondiagnostic. Two blinded readers (cardiologist and emergency physician) independently categorized each PHTL. A third reviewer assigned final diagnoses and determined whether the PHTL met STEMI criteria. One hundred sixty-six PHTL were acquired over an 8-month period. Fifteen were excluded from analysis. Sixty-two percent of the patients (94/151) were male, mean age was 61.1 years (+/-14.8 SD, range 20-92 years), and 81% had chest pain. Twenty-five patients (16.6%; 95% confidence interval [CI], 11%-23.5%) had confirmed STEMI and 16 (10.6%) had confirmed non-STEMI acute myocardial infarction. Paramedic sensitivity was 0.80 (95% CI, 0.64-0.96); specificity was 0.97 (95% CI, 0.94-1.00) with positive likelihood ratio of 25.2 and negative likelihood ratio of 0.21. Overall accuracy was similar for paramedic and physician reviewers (0.94, 0.93, 0.95). Highly trained paramedics in an urban emergency medical services system can identify patients with STEMI as accurately as blinded physician reviewers.

Pretreatment with statins enhances myocardial protection during coronary revascularization.

OBJECTIVE: This experimental study was undertaken to determine whether pretreatment with statins would enhance myocardial protection and minimize ischemic injury during revascularization of acutely ischemic myocardium. METHODS: In 20 pigs the second and third diagonal arteries were occluded for 90 minutes, followed by 45 minutes of blood cardioplegic arrest and 180 minutes of reperfusion. Ten pigs received atorvastatin (40 mg orally every day) for 21 days before surgical intervention; 10 others received no statins. Ischemic damage was assessed on the basis of the need for cardioversions for ventricular arrhythmias, regional wall-motion scores (4 = normal to -1 = dyskinesia) were determined by means of 2-dimensional echocardiography, endothelial function was assessed on the basis of bradykinin-induced coronary artery relaxation, and infarct size was calculated by determining the area of necrosis to the area of risk by means of histochemical staining. Results are given as means +/- SE. RESULTS: Statin-treated animals required fewer cardioversions (0.11 +/- 0.01 vs 2.87 +/- 0.20, P =.0001), had improved wall-motion scores (2.81 +/- 0.10 vs 1.52 +/- 0.08, P =.01), had lower infarct size (21% +/- 2% vs 41% +/- 2%, P =.0001), and had more complete coronary artery relaxation (34% +/- 5% vs 8% +/- 4%, P =.01). Total serum cholesterol levels were similar between the groups (62 +/- 5 mg/dL for statin-treated animals vs 68 +/- 5 mg/dL for non-statin-treated animals, P =.30). CONCLUSIONS: Pretreatment with statins enhances myocardial protection during revascularization by means of mechanisms that are independent of their cholesterol-lowering properties.

Pretreatment with angiotensin-converting enzyme inhibitors attenuates ischemia-reperfusion injury.

BACKGROUND: The Heart Outcomes Prevention Evaluation (HOPE) trial demonstrated that ischemic events are decreased in patients receiving angiotensin-converting enzyme (ACE) inhibitors. This study sought to determine whether pretreatment with ACE inhibitors would attentuate ischemic injury during surgical revascularization of ischemic myocardium. METHODS: In a porcine model, the second and third diagonal vessels were occluded for 90 minutes, followed by 45 minutes of cardioplegic arrest, and 180 minutes of reperfusion. Ten pigs received quinapril (20 mg p.o. q.d.) for 7 days prior to surgery; 10 others received no-ACE inhibitors. RESULTS: Quinapril-treated animals required less cardioversions for ventricular arrhythmias (1.58 +/- 0.40 vs 2.77 +/- 0.22; p < 0.05), had higher wall motion scores assessed by two-dimensional echocardiography (4 = normal to -1 = dyskinesia; 2.11 +/- 0.10 vs 1.50 +/- 0.07; p < 0.05), more complete coronary artery endothelial relaxation to bradykinin (45% +/- 3% vs 7% +/- 4%; p < 0.005), and lower infarct size (24.0% +/- 3.0% vs 40.0% +/- 1.7%; p < 0.0001). CONCLUSIONS: ACE inhibition prior to coronary revascularization enhances myocardial protection by decreasing ventricular irritability, improving regional wall motion, lowering infarct size, and preserving endothelial function.