RESUMEN
We present the case of a 93-year-old woman with dementia, with no pertinent cardiac history except for hyperlipidemia, who presented to the emergency department with six months of progressive dysphagia, weakness, and falls. While she had no seemingly cardiac symptoms and or remarkable cardiovascular examination features, the patient's initial electrocardiogram (ECG) showed occasional brief pauses with no atrial or ventricular activity. Computer interpretation of the rhythm was "sinus pause," but upon closer investigation, the true diagnosis was different, but with potential to be equally ominous if not accurately recognized and appropriately managed.
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Complejos Atriales Prematuros , Paro Cardíaco , Anciano , Anciano de 80 o más Años , Electrocardiografía , Femenino , Atrios Cardíacos , HumanosRESUMEN
Hyperkalemia is a recognized and potentially life-threatening complication of heart transplantation. In the complex biosystem created by transplantation, recipients are susceptible to multiple mechanisms for hyperkalemia which are discussed in detail in this manuscript. Hyperkalemia in heart transplantation could occur pre-transplant, during the transplant period, or post-transplant. Pre-transplant causes of hyperkalemia include hypothermia, donor heart preservation solutions, conventional cardioplegia, normokalemic cardioplegia, continuous warm reperfusion technique, and ex-vivo heart perfusion. Intra-transplant causes of hyperkalemia include anesthetic medications used during the procedure, heparinization, blood transfusions, and a low output state. Finally, post-transplant causes of hyperkalemia include hemostasis and drug-induced hyperkalemia. Hyperkalemia has been studied in kidney and liver transplant recipients, but there is limited data on the incidence, causes, management, and prevention in heart transplant recipients. Hyperkalemia is associated with an increased risk of hospital mortality and readmission in these patients. This review describes the current literature pertaining to the causes, pathophysiology, and treatment of hyperkalemia in patients undergoing heart transplantation and focuses primarily on post-heart transplantation.
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Estenosis de la Válvula Aórtica/cirugía , Mortalidad Hospitalaria , Fallo Renal Crónico/complicaciones , Complicaciones Posoperatorias/epidemiología , Insuficiencia Renal Crónica/complicaciones , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/complicaciones , Estudios de Cohortes , Femenino , Humanos , Fallo Renal Crónico/terapia , Tiempo de Internación/estadística & datos numéricos , Masculino , Readmisión del Paciente , Diálisis Renal , Estudios Retrospectivos , Reemplazo de la Válvula Aórtica TranscatéterRESUMEN
Renal artery stenosis is a cause of resistant hypertension, which can present with several features such as severe hypertension, deterioration of renal function (with or without associated angiotensin-converting inhibitor or angiotensin receptor blocker therapy), and flash pulmonary edema. When evaluating for the presence of renal artery stenosis, the most widely utilized imaging modalities are duplex ultrasonography and computed tomography angiography. In this article, we discuss the case of a 77-year-old female who presented with shortness of breath and mild pulmonary edema, secondary to hypertensive emergency. Later, she was diagnosed with renal artery stenosis and underwent stent placement in the left renal artery. Our case highlights the different diagnostic modalities and emphasizes that the most commonly used screening, which is duplex ultrasonography, was performed on our patient but gave a false-negative result, despite high-grade stenosis, which was later diagnosed on computed tomography angiography.
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Hipertensión Renovascular/etiología , Obstrucción de la Arteria Renal/diagnóstico por imagen , Arteria Renal/diagnóstico por imagen , Anciano , Antihipertensivos/uso terapéutico , Terapia Combinada , Angiografía por Tomografía Computarizada , Reacciones Falso Negativas , Femenino , Humanos , Hipertensión Renovascular/terapia , Arteria Renal/cirugía , Obstrucción de la Arteria Renal/cirugía , Stents , Resultado del Tratamiento , Ultrasonografía Doppler Dúplex/métodosRESUMEN
OBJECTIVE: We examined low risk (LR) patients admitted to our chest pain unit (CPU) with negative cardiac injury markers, normal electrocardiogram, and clinical stability. We hypothesized that there is a sub-group of intermediate risk (IR) patients within the larger LR population. METHODS: Criteria for IR were the aforementioned 3 indicators of LR and ≥1 of the following: (1) known coronary artery disease (CAD), (2) men ≥45 yo, women ≥55 yo, and (3) ≥3 cardiac risk factors. We compared patient characteristics, use of pre-discharge testing (PDT), and major adverse cardiac events (MACE). RESULTS: IR patients numbered 371, whereas LR patients totaled 70. IR patients were older (61 vs 46 years), more had known CAD (28 vs. 0%), had a higher median number of risk factors (2 vs. 1) and were less likely to be women (49 vs. 81%), all P < 0.0001. IR patients received a greater median number of tests compared with LR patients (1 vs. 0, P < 0.0001). CONCLUSIONS: Among the IR group, 16 patients (4%) had a cardiac event at the index CPU visit, 2 (0.5%) experienced MACE at 30-day follow-up, and 2 (0.5%) had MACE at 6 months follow-up. No LR patients had MACE at any point in the study. Thus, the majority of CPU patients are IR, have more risk factors than LR group, and are more likely to receive PDT. IR patients were managed safely in a CPU, while maintaining low rates of MACE post-discharge.
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Síndrome Coronario Agudo/diagnóstico , Dolor en el Pecho/etiología , Síndrome Coronario Agudo/complicaciones , Síndrome Coronario Agudo/epidemiología , Síndrome Coronario Agudo/metabolismo , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/mortalidad , Dolor en el Pecho/epidemiología , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/epidemiología , Manejo de la Enfermedad , Ecocardiografía de Estrés , Electrocardiografía , Prueba de Esfuerzo , Femenino , Factores de Riesgo de Enfermedad Cardiaca , Unidades Hospitalarias , Hospitalización , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Infarto del Miocardio , Imagen de Perfusión Miocárdica , Revascularización Miocárdica/estadística & datos numéricos , Alta del Paciente , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Troponina I/metabolismo , Adulto JovenRESUMEN
The burden of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is staggering on a national and global level. Yet, surprisingly, there is a profound lack of treatment standardization with glucocorticoids in the treatment of AECOPD. In this review, we bring attention to specific literature that use a cut-off of 60 mg prednisone equivalent per day when distinguishing between high-dose and low-dose glucocorticoid treatment. We hope this review encourages future research to begin incrementally lowering the cut-off dose of 60 mg to discover if mortality, length of hospital stays, and readmission rates change between high-dose and low-dose glucocorticoid treatment. The final hope would be to establish an optimal glucocorticoid dose to treat AECOPD and eliminate treatment ambiguity.
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Progresión de la Enfermedad , Glucocorticoides/uso terapéutico , Tiempo de Internación , Readmisión del Paciente/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Relación Dosis-Respuesta a Droga , Humanos , Placebos , Enfermedad Pulmonar Obstructiva Crónica/diagnósticoRESUMEN
Abdominal aortic aneurysm (AAA) is one of the important pathologies involving the abdominal aorta, as it can have adverse consequences if it goes unnoticed or untreated. AAA is defined as an abnormal dilation of the abdominal aorta 3 cm or greater. Endovascular abdominal aortic aneurysm repair (EVAR) has recently emerged as a treatment modality for AAA. It does have a few inherent complications that include endoleak, endograft migration, bleeding, ischemia, and compartment syndrome. This case report discusses a patient who came in with abdominal pain and a pulsatile mass, which raised concerns regarding endoleak. The patient had a 9.9-cm AAA, which was repaired in the past, as was made evident by computed tomography findings of the stent graft in the aneurysmal segment. This case stands out because it highlights the importance of comparing the size of the AAA at the time of the EVAR to the current scenario where the patient presents with abdominal pain of unknown etiology. Also, this case report highlights the importance of computed tomography and other imaging forms in following-up with patients who have EVAR for AAAs.
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Dolor Abdominal/etiología , Aneurisma de la Aorta Abdominal/cirugía , Endofuga/diagnóstico , Procedimientos Endovasculares/efectos adversos , Complicaciones Posoperatorias/etiología , Anciano , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Endofuga/diagnóstico por imagen , Endofuga/etiología , Humanos , Masculino , Complicaciones Posoperatorias/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
Predischarge cardiac testing (PDT) in low-risk patients evaluated for acute coronary syndrome in a chest pain unit (CPU) remains a challenge. It is unclear whether PDT varies by gender. We analyzed consecutive low-risk women and men evaluated in our CPU over a 2-year period and compared the utilization of PDT (exercise treadmill test, myocardial stress perfusion scintigraphy, exercise stress echocardiography, invasive coronary angiography, or no test), and incidence of major adverse cardiac events (MACE) at 30 days and 6 months. The study group comprised 619 patients (54% women). A large proportion of both genders did not undergo PDT, although this finding was more frequent in women (50% women vs 40% men, pâ¯=â¯0.01). At 30 days, there were no MACE in either gender. After 6 months of follow-up, MACE remained very low in both women and men (2 [1%] vs 2 [1%]), and in patients who did and did not receive PDT (2 [1%] vs 2 [1%]). Mean length of stay in the CPU was 5.4 hours in patients without PDT and 9.8 hours in those with PDT (p <0.0001) without altering postdischarge MACE. When referred for PDT, women more often underwent myocardial stress perfusion scintigraphy than men (22% vs 14%, pâ¯=â¯0.005) and less often received exercise treadmill test (20% vs 39%, p <0.0001). Yield of abnormal PDT was low in both women and men although it was lower in women (1% vs 5%, pâ¯=â¯0.02). In conclusion, many low-risk women and men evaluated in a CPU for acute coronary syndrome can be safely and rapidly discharged without PDT and with low risk for MACE at 30 days and at 6 months. Exclusion of PDT was associated with significantly reduced length of stay while maintaining safety in terms of postdischarge MACE.