[FATE echocardiography at the emergency outpatient unit]. / Sydämen FATE-kaikukuvaus päivystyspoliklinikassa.

FATE (Focus Assessed Transthoracic Echocardiography) echocardiography can be learned more quickly than extensive cardiologic examination. It is intended to be used in emergency situations as a qualitative examination to resolve the cardiogenic mechanism of circulatory insufficiency and possible hypovolemia. The procedure is worth utilizing as a dynamic method in the assessment of the response to fluid therapy and vasoactive medications. In many cases, however, a more profound ultrasound imaging will provide essential further information.

Simplifying the estimation of jugular venous pressure.

The classic technique of estimating jugular venous pressure, with variable inclination of the upper body and the sternal angle as the reference point, is complicated and little used in general practice. The aim of this prospective, comparative study was to assess whether estimating neck vein distension with the patient in the sitting position could be used to detecting elevated venous pressure. Patients (n = 96) who underwent right-sided cardiac catheterization or endomyocardial biopsy were evaluated. The visible height of the right internal jugular venous column above the clavicle was estimated, and the mean pressure in the right atrium or superior vena cava at cardiac catheterization was measured. Invasive venous pressure was elevated (>8 mm Hg) in 23 patients. A deep venous column visibly distended above the right clavicle in the sitting position had sensitivity of 65% and specificity of 85% to identify truly elevated venous pressure. Abdominal compression increased sensitivity to 77% but decreased specificity to 68%. In conclusion, studying the deep neck veins of a sitting patient simplifies the estimation of jugular venous pressure and has moderate to high diagnostic performance in detecting elevated central venous pressure.

Magnetocardiographic indices of left ventricular hypertrophy.

OBJECTIVE: We tested the hypothesis that multichannel magnetocardiographic (MCG) mapping can detect and quantify the degree of left ventricular hypertrophy (LVH). DESIGN: A cross-sectional study. SETTING: Helsinki University Central Hospital, a tertiary referral center. PARTICIPANTS: Forty-two patients with pressure overload induced LVH by gender-specific echocardiographic criteria (LVH group), and 12 healthy middle-aged controls. MAIN OUTCOME MEASURES: MCG QRS-T area integrals and QRS-T angle in magnetic field maps in relation to echocardiographic LVH as well as left ventricular (LV) mass and structure. Conventional 12-lead electrocardiographic (ECG) LVH indices (Sokolow-Lyon voltage, Cornell voltage, Cornell voltage duration product) were assessed for comparison. RESULTS: MCG QRS- and T-wave integrals provided complementary information of echocardiographic LV mass. Their combination, the QRS-T integral, and the QRS-T angle were increased in patients with LVH and, in those patients, correlated significantly with LV mass indexed to body surface area (r = 0.455;P = 0.002 and r= 0.379; P= 0.013, respectively). A QRS-T integral 16000 fT.s had identical sensitivity of 62% at 92% specificity as the gender-adjusted Cornell voltage duration product of 240 micro V.s for the detection of LVH. CONCLUSIONS: The MCG method can detect patients with LVH and also quantify the degree of LVH in patients with increased LV mass.

Dexmedetomidine in addition to benzodiazepine-based sedation in patients with alcohol withdrawal delirium.

Alcohol withdrawal delirium (AWD) is often refractory to conventional medication. We report a prospective series of patients treated with α2-agonist dexmedetomidine added to conventional sedation. Eighteen patients with AWD were diagnosed by Confusion assessment method for ICU score. Treatment, complications, length of stay (LOS) in ICU and hospital were recorded. In addition, hospital and 1-year mortality were assessed. Dexmedetomidine was given for 23.9 (18.4) h [mean (SD)]. All the patients also received benzodiazepines but three patients were given haloperidole. No patient was intubated. The maximum infusion rate of dexmedetomidine was 1.5 (1.2) µg/kg/h. Time to resolution of AWD was 3.8 (1.3) days. The ICU LOS was 7.1 (2.7) days and in-hospital LOS 12.1 (4.5) days. No adverse events were observed although one patient died from acute pancreatitis. The use of dexmedetomidine in AWD seems safe but warrants further studies.

The use of more than one inotrope in acute heart failure is associated with increased mortality: a multi-centre observational study.

BACKGROUND: Although weakly supported by scientific evidence, according to guidelines the use of inotropes in acute heart failure is indicated in the presence of hypoperfusion refractory to fluid resuscitation. AIMS: We examined the characteristics of the inotrope-treated patients, as well as, their in-hospital mortality. The frequency and dosing of inotropic infusions in patients admitted with acute heart failure was assessed in detail. METHODS: We included 620 consecutive patients with acute heart failure who were admitted to hospital during three months during spring 2004 in an observational multi-centre study. RESULTS: Of the patients 84 (14%) were treated with inotropes. Dopamine was used in 46 (7%), dobutamine 22 (4%), epinephrine 5 (1%), norepinephrine in 33 (5%), and levosimendan in 44 (7%) cases. The in-hospital mortality was 21% in the inotrope-treated group, and 5% in the control group. The mortality was 7% if only one inotrope was used. The mortality increased in proportion to the number of inotropes used. Lower blood pressure at admission, low ejection fraction, elevated C-reactive protein and cardiac markers correlated with the inotrope administration. CONCLUSION: Inotrope administration is a marker of increased mortality in patients with acute heart failure. Still, the use of a single inotrope during hospital stay seems rather safe.

Quality of emergency room care for atrial fibrillation.

OBJECTIVES: Atrial fibrillation (AF) is the most common arrhythmia in emergency rooms (ER). We surveyed the clinical characteristics and quality of care of AF patients in three emergency rooms in Helsinki, Finland. DESIGN: Observational data of the treatment of 179 consecutive symptomatic AF patients were prospectively collected. The quality of care was analysed according to a predestined set of criteria. RESULTS: Mean age of the patients was 63 years and 61% were men. The leading symptom was palpitation (86%). Sinus rhythm was achieved in 70%. New anticoagulation was initiated in 20% and cardiovascular medication modified in 42% of patients. Considering the overall quality of care, including documentation in the patient chart, it was classified as good in 53% of all patients, whereas the quality of therapeutic decisions and planning for follow-up was good in 77%. CONCLUSIONS: The ER visit results in extensive treatment modifications in two of three patients. Although inadequate care is rare, maintaining good quality requires adherence to clinical guidelines, careful documentation and plans for follow-up.