Trends in outpatient transthoracic echocardiography: impact of appropriateness criteria publication.

BACKGROUND: The impact of the 2007 American College of Cardiology Foundation Transthoracic Echocardiography Appropriateness Criteria on trends in appropriateness is unknown. Therefore, we sought to identify the appropriateness of outpatient transthoracic echocardiography pre- and postpublication of this document. METHODS: The 2007 Appropriateness Criteria were used to classify outpatient echocardiographic studies at an academic medical center during October 2000 and October 2008. The patient's electronic medical record was used to identify echocardiographic indication and appropriateness. RESULTS: From October 2000 to October 2008, there was an 85% increase in outpatient echocardiographic volume. Using the Appropriateness Criteria, there was no significant change in inappropriate referrals (13% and 15%, P=.58). Sixty-five studies (12%) were referred for indications "not addressed" by the document, with an increase (7% to 15%, P=.012) from 2000 to 2008. In a second analysis, incorporating the 2008 Valve Guidelines, an increase was demonstrated in the total number of studies that could be classified, but there was no significant change in the proportion of inappropriate referrals (P=.50). There remained a significant increase (3% to 10%, P=.009) in the proportion of indications "not addressed" by either guideline. CONCLUSION: From October 2000 to October 2008, we experienced a near doubling of outpatient echocardiographic volume, with no significant change in the percent of inappropriate referrals despite interim publication of the Appropriateness Criteria document. In addition, there was an increase in echocardiographic referrals for "not addressed" indications. Future efforts are needed both to refine the Appropriateness Criteria to include unaddressed indications and to promote its effective implementation.

Improper renal dosing in long-term care facilities.

OBJECTIVES: With advancing age, physiologic changes occur that affect drug metabolism. Possibly the most predictable function decline in geriatric population is renal function. METHODS: The prescribing habits of physicians and the attention given to patient renal function was investigated. Data was collected from two nursing facilities in southeastern Georgia. RESULTS: Based on two models of prescribing habits and using logistic regression estimates, we concluded that physicians do not follow recommendations for dose adjustment of renally excreted medications in these two facilities. CONCLUSION: We recommend that physicians consider evaluating current medications and establishing a base line for renal function and degree of decline.

Cerebral hemorrhage: precipitating event for a tako-tsubo-like cardiomyopathy?

There have been some reports in medical literature of patients with profound, reversible left-ventricular (LV) dysfunction after sudden emotional stress. Originally, in Japan, the pattern was called tako-tsubo cardiomyopathy. ST-segment elevation is seen with this syndrome, and it may look like acute ST-elevation myocardial infarction. However, it has also been well established that a subarachnoid hemorrhage can manifest with cardiac abnormalities. The authors describe a case involving a cerebral hemorrhage and a potential tako-tsubo-like cardiomyopathy in the same patient. In conclusion, even though the patient's presentation appears to be a tako-tsubo syndrome, the radiographic evidence of a cerebral hemorrhage presents as a stronger etiology for the cardiac changes that occur in our patient.

Financial barriers to health care and outcomes after acute myocardial infarction.

CONTEXT: The prevalence and consequences of financial barriers to health care services and medications are not well documented for patients with an acute myocardial infarction (AMI). OBJECTIVE: To measure the baseline prevalence of self-reported financial barriers to health care services or medication (as defined by avoidance due to cost) among individuals following AMI and their association with subsequent health care outcomes. DESIGN, SETTING, AND PARTICIPANTS: The Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), an observational, multicenter US study of patients with AMI over 12 months in 2498 individuals enrolled from January 2003 through June 2004. MAIN OUTCOME MEASURES: Health status symptoms (Seattle Angina Questionnaire [SAQ]), overall health status function (Short Form-12), and rehospitalization. RESULTS: The prevalence of self-reported financial barriers to health care services or medication was 18.1% and 12.9%, respectively. Among individuals who reported financial barriers to health care services or medication, 68.9% and 68.5%, respectively, were insured. At 1-year follow-up, individuals with financial barriers to health care services were more likely to have lower SAQ quality-of-life score (77.9 vs 86.2; adjusted mean difference= -4.0; 95% confidence interval [CI], -6.3 to -1.8), and increased rates of all-cause rehospitalization (49.3% vs 38.1%; adjusted hazard ratio [HR], 1.3; 95% CI, 1.1-1.5) and cardiac rehospitalization (25.7% vs 17.7%; adjusted HR, 1.3; 95% CI, 1.0-1.6). At 1-year follow-up, individuals with financial barriers to medication were more likely to have angina (34.9% vs 17.9%; adjusted odds ratio, 1.55; 95% CI, 1.1-2.2), lower SAQ quality-of-life score (74.0 vs 86.1; adjusted mean difference = -7.6; 95% CI, -10.2 to -4.9), and increased rates of all-cause rehospitalization (57.0% vs 37.8%; risk-adjusted HR, 1.5; 95% CI, 1.2-1.8) and cardiac rehospitalization (33.7% vs 17.3%; adjusted HR, 1.7; 95% CI, 1.3-2.2). CONCLUSION: Financial barriers to health care services and medications are associated with worse recovery after AMI, manifested as more angina, poorer quality of life, and higher risk of rehospitalization.

Clinical correlation between effective anticoagulants and risk of stroke: are we using evidence-based strategies?

OBJECTIVES: Despite evidence supporting anticoagulant use in atrial fibrillation, this modality is not fully utilized. METHODS: Retrospective chart review of 297 patients with nonvalvular atrial fibrillation between 1997 to 2000. 124 patients received warfarin and 166 did not; 91 patients suffered stroke. RESULTS: Age (P = 0.232) and gender (P = 0.745) were not determinant factors for starting anticoagulation prophylaxis. Whites were more likely to receive anticoagulation therapy than blacks (P = 0.043). Cardiologists were 4.5 times more likely to prescribe warfarin than neurologists and internists (P = 0.035). Neurologists (P = 0.305) and internists (P = 0.770) had similar warfarin prescription patterns and often with patients experiencing the highest rates of stroke. CONCLUSION: Lack of a uniform pattern in anticoagulant administration, despite multiple guidelines, is disturbing. Continuous physician education and community awareness by local and federal medical agencies is essential and cost-effective.

Evaluation of lactate and C-reactive protein in the assessment of acute myocardial infarction.

PURPOSE: The purpose of this study was to assess the usefulness of lactate and C-reactive protein as early markers of acute myocardial infarction (AMI) in conjunction with established markers, such as creatine phosphokinase (CPK)-MB and troponin I. METHODS: The study population consisted of all patients admitted with suspected AMI regardless of age, race, gender, or comorbid conditions. All patients in cardiac heart failure or cardiogenic shock were excluded. Lactate and C-reactive protein were drawn at admission, and then at 2 and 4 hours, respectively. The positive and negative predictive values of these markers were calculated in relation to the primary outcome measure. RESULTS: A total of 62 patients were enrolled in the study. Of those, 18 patients had documented AMI and all underwent thrombolysis, thrombolysis with angioplasty, or stent placement. The lactate was measured at 2 and 4 hours, and lactate levels correlated with CPK and CPK-MB, in addition to troponin I. In our cohort, lactate had a sensitivity of 75% and a specificity of 95.5%, with a positive predictive value of 85.7% and a negative predictive value of 91.3%. CONCLUSION: As an inexpensive and readily available marker for AMI, lactate seems to be reliable and could be used in an emergency setting to facilitate the decision-making process for chest pain syndrome. It would be a helpful adjunct on whether the patient can be safely discharged or should be promptly admitted.

Haemophilus aphrophilus endocarditis after tongue piercing.

Piercing invades subcutaneous areas and has a high potential for infectious complications. The number of case reports of endocarditis associated with piercing is increasing. We studied a 25-year-old man with a pierced tongue, who arrived at Memorial Health University Medical Center with fever, chills, rigors, and shortness of breath of 6 days' duration and had an aortic valvuloplasty for correction of congenital aortic stenosis.