Orthopedic injuries associated with jet-skis (personal watercrafts): A review of 127 inpatients.

BACKGROUND: Personal watercrafts (PWC) account for a disproportionate amount of water based injuries. Current literature suggests those with less PWC experience are more at risk for injury. Previous studies have not specifically evaluated the orthopedic implications of PWC usage or how various mechanisms of injury (MOI) contribute to different injury patterns. HYPOTHESIS: PWC injuries will frequently require orthopedic intervention. The presence of an orthopedic injury will result in increased injury severity score (ISS), hospital and intensive care unit (ICU) length of stay (LOS). Patients visiting our region will have less PWC experience and so are more prone to serious injuries. MATERIALS AND METHODS: Retrospective cohort study at a single Level 1 trauma center of admitted patients sustaining PWC injuries from 02/2004-03/2017. The following were studied: demographics, mechanism, season, ISS, hospital and ICU LOS, follow-up, fracture characteristics and management. RESULTS: Hundred and twenty-seven patients were admitted due to PWC injury, 66 (52.0%) sustained an orthopedic injury, totaling 103 fractures (48 [46.6%] lower extremity, 26 [25.2%] upper extremity, 14 [13.6%] vertebral, 11 [10.7%] pelvic ring and 4 [3.9%] acetabulum). The mean age of orthopedic patients was 29 years (range 8-62). Handle bar injuries were significantly associated with open fractures, (13 of 25 open fractures, 3 of which became infected). Injuries occurring during the winter were associated with a higher ISS, yet more injuries occurred in the summer. A patient being a "visitor" to the region did not influence ISS. The mean LOS was 12.6 days for orthopedic patients. Eighteen orthopedic patients (27.3%) required ICU admission and 36 (54.5%) patients required orthopedic surgery (mean 2.11 operations). DISCUSSION: A majority of PWC injuries resulted in extremity fractures with a moderate percentage requiring orthopedic surgery. Correlations between PWC experience and injury incidence can provide information for increased safety. LEVEL OF EVIDENCE: IV; retrospective.

Clot-bound thrombin is protected from inhibition by heparin-antithrombin III but is susceptible to inactivation by antithrombin III-independent inhibitors.

Propagation of venous thrombi or rethrombosis after coronary thrombolytic therapy can occur despite heparin administration. To explore potential mechanisms, we set out to determine whether clot-bound thrombin is relatively protected from inhibition by heparin-antithrombin III but susceptible to inactivation by antithrombin III-independent inhibitors. Using plasma fibrinopeptide A (FPA) levels as an index of thrombin activity, we compared the ability of thrombin inhibitors to block FPA release mediated by fluid-phase thrombin with their activity against the clot-bound enzyme. Incubation of thrombin with citrated plasma results in concentration-dependent FPA generation, which reaches a plateau within minutes. In contrast, there is progressive FPA generation when fibrin clots are incubated with citrated plasma. Heparin, hirudin, hirudin dodecapeptide (hirugen), and D-phenylalanyl-L-prolyl-L-arginyl chloromethyl ketone (PPACK) produce concentration-dependent inhibition of FPA release mediated by fluid-phase thrombin. However, heparin is much less effective at inhibiting thrombin bound to fibrin because a 20-fold higher concentration is necessary to block 70% of the activity of the clot-bound enzyme than is required for equivalent inhibition of fluid-phase thrombin (2.0 and 0.1 U/ml, respectively). In contrast, hirugen and PPACK are equally effective inhibitors of fluid- and solid-phase thrombin, while hirudin is only 50% as effective against the clot-bound enzyme. None of the inhibitors displace bound 125I-labeled thrombin from the clot. These studies indicate that (a) clot-bound thrombin is relatively protected from inhibition by heparin, possibly because the heparin binding site on thrombin is inaccessible when the enzyme is bound to fibrin, and (b) clot-bound thrombin is susceptible to inactivation by antithrombin III-independent inhibitors because the sites of their interaction are not masked by thrombin binding to fibrin. For these reasons, antithrombin III-independent inhibitors may be more effective than heparin in certain clinical settings.

Risks and benefits of adding anti-platelet therapy to warfarin among patients with prosthetic heart valves: a meta-analysis.

OBJECTIVES: The objective of this study was to compare the effectiveness and safety of adding dipyridamole or aspirin to warfarin among patients with prosthetic heart valves using meta-analytic techniques. BACKGROUND: Patients with prosthetic heart valves are at increased risk for valve thrombosis and arterial thromboembolism. Oral anticoagulation alone, or the addition of antiplatelet drugs, has been used to minimize this risk. An important issue is the effectiveness and safety of the latter strategy. METHODS: A combined MEDLINE and manual search was made for relevant articles from 1966 to November 1999. Standard meta-analysis techniques were used. RESULTS: Ten studies involving 2,199 subjects met the inclusion criteria. Compared with anticoagulation alone, the addition of an antiplatelet agent reduced the risk of thromboembolic events (odds ratio [OR]: 0.41, p < 0.001) and total mortality (OR: 0.49, p < 0.001). The risk of major bleeding was increased when antiplatelet agents were added (OR: 1.50, p = 0.033). For major bleeding, the comparison of trials performed before and after 1990 (OR: 2.23 and 0.88, respectively) showed that the chi-square test for heterogeneity was significant (p = 0.025). The latter trials used low-dose aspirin, suggesting that the risk of bleeding may be lower with contemporary low-dose (100 mg daily) aspirin. CONCLUSIONS: Adding antiplatelet therapy, especially low-dose aspirin, to warfarin decreases the risk of systemic embolism or death among patients with prosthetic heart valves. The risk of major bleeding is slightly increased with antiplatelet therapy. Nonetheless, the risk of bleeding appears to have diminished with the lower doses of aspirin used in the more recent trials, resulting in a favorable risk-to-benefit profile.

Patient reperfusion preferences in acute myocardial infarction: mortality versus stroke, benefits versus costs, high technology versus drugs.

BACKGROUND: Reperfusion therapy, thrombolysis and primary percutaneous coronary intervention (PCI) decrease mortality in ST elevation acute myocardial infarction. Tissue plasminogen activator (tPA) reduces the risk of death but at an increased risk of stroke and cost compared with streptokinase (SK). PCI reduces the risk of death and stroke compared with tPA, but at increased costs. The authors explored patient preferences for the various reperfusion strategies. PATIENTS AND METHODS: Among patients hospitalized with an acute coronary syndrome, preferences for tPA or SK were determined using a questionnaire based on Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial data including risk of death, stroke and the combination of the two. The impact of cost was assessed under the assumption of government or patient payment. Overall, the societal preference was solicited based on all the data. A similar survey was conducted comparing primary PCI with tPA using outcome data from a Cochrane review. RESULTS: When viewed in the context of net clinical benefit (NCB), 66.7% of patients chose tPA over SK. The preference for tPA diminished under the scenario of patient payment compared with government payment. However, as a societal strategy, the preference for tPA was 40.5% (P<0.001 versus NCB). Preference for primary PCI over tPA was strong whether based on risk of death (78.5%), stroke (88.1%) or NCB (95.4%). Cost considerations resulted in a slight fall in PCI preference (87.7%). As an overall societal strategy, 81.0% chose primary PCI over tPA (P=0.016 versus NCB). The preference for PCI was twice that for the most effective, but perhaps riskier, thrombolytic agent (tPA) (P<0.0001). CONCLUSIONS: Preference for the potentially inferior thrombolytic agent appears to depend on the lesser risk of stroke and the lower cost. Primary PCI was preferred by patients likely due to the lower risk of death and stroke, despite the increased cost. The preferences appeared to be influenced by societal costs. In addition, the allure and heightened expectations of high technology may play a role.

A systematic review of the cost-effectiveness of noncardiac transitional care units.

OBJECTIVE: To critically appraise and summarize the studies examining the cost-effectiveness of noncardiac transitional care units (TCUs). DATA SOURCES: We conducted a computerized literature search using MEDLINE, and Current Contents from January 1, 1986 to December 31, 1995 and HealthSTAR from January 1, 1989 to December 31, 1995 with the key words intermediate care unit, respiratory care unit, and step-down unit. Bibliographies of all selected articles and review articles were examined. Personal files were also reviewed. STUDY SELECTION: (1) POPULATION: patients in a noncardiac TCU of an acute-care institution; (2) intervention: addition of a noncardiac TCU to the institution; and (3) outcomes: patient outcome-survival and associated costs. DATA EXTRACTION: The necessary data were abstracted and study validity was evaluated by two independent reviewers using a modification of previously published criteria. DATA SYNTHESIS: The studies were summarized qualitatively; upon inspection, they were too heterogeneous to allow quantitative analysis. While the studies all claimed that their TCUs were cost-effective, the economic evaluation designs were flawed to such an extent that the validity of the conclusions is suspect. CONCLUSIONS: To date, the evidence in the literature is insufficient to determine under which circumstances, if any, TCUs are a cost-effective alternative technology to the traditional institution with only ICU and general ward beds.

Propranolol for the prevention of postoperative arrhythmias in general thoracic surgery.

BACKGROUND: Prevention of postoperative arrhythmias in patients undergoing general thoracic surgery is desirable to prevent morbidity. METHODS: A randomized, double-blind, placebo controlled trial of propranolol (10 mg every 6 hours) for 5 days was undertaken in patients undergoing major thoracic operations to determine whether arrhythmias requiring treatment could be reduced. Secondary outcomes included overall arrhythmia rate, adverse events, and length of stay. Arrhythmias were assessed by 72-hour Holter monitoring. Patients with a history of heart failure, asthma, advanced heart block, preexisting arrhythmias, sensitivity to propranolol, or use of antiarrhythmic drugs were excluded. RESULTS: Using the intention-to-treat principle there was a 70% relative risk reduction from 20% to 6% in the rate of treated arrhythmias with propranolol (p = 0.071, 95% confidence interval 0.6% to 27.2%). Overall arrhythmias were common but usually benign. Adverse effects were common, although generally mild with hypotension and bradycardia being reported more often in the propranolol group. Length of stay was not different. CONCLUSIONS: There was a trend to a reduction in the risk of perioperative arrhythmias with propranolol. Moreover, propranolol was well tolerated showing a slight increase in minor adverse events.

Antiplatelet and anticoagulation for patients with prosthetic heart valves.

BACKGROUND: Patients with prosthetic heart valves are at increased risk for valve thrombosis and arterial thromboembolism. Oral anticoagulation alone, or the addition of antiplatelet drugs, has been used to minimize this risk. An important issue is the effectiveness and safety of the latter strategy. OBJECTIVES: To compare the effectiveness and safety of adding antiplatelet therapy to standard oral anticoagulation among patients with prosthetic heart valves. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 2, 2003), MEDLINE (January 1966 to August 2002), EMBASE (January 1988 to July 2001) and reference lists of individual reports, review articles, meta-analyses, and consensus statements. SELECTION CRITERIA: All reports of randomised controlled trials comparing standard dose oral anticoagulation to standard dose oral anticoagulation and antiplatelet therapy in patients with one or more prosthetic heart valves. We included reports published in any language or in abstract form. DATA COLLECTION AND ANALYSIS: Two reviewers independently performed the search strategy, assessed trials for inclusion criteria, study quality, and extracted data. Adverse effects information was collected from the trials. MAIN RESULTS: Eleven studies involving 2,428 subjects met the inclusion criteria. Year of publication ranged from 1971 to 2000. Compared with anticoagulation alone, the addition of an antiplatelet agent reduced the risk of thromboembolic events (odds ratio 0.39 (95% confidence interval 0.28 to 0.56; p<0.00001)) and total mortality (odds ratio 0.55 (95% confidence interval 0.40 to 0.77; p=0.0003)). Aspirin and dipyridamole reduced these events similarly. The risk of major bleeding was increased when antiplatelet agents were added to oral anticoagulants (odds ratio 1.66 (95% confidence interval 1.18 to 2.34; p=0.003)). For major bleeding, there was no evidence of heterogeneity between aspirin and dipyridamole and in the comparison of trials performed before and after 1990, around the time when anticoagulation standardization with the international normalized ratio was being implemented. REVIEWER'S CONCLUSIONS: Adding antiplatelet therapy, either dipyridamole or low-dose aspirin, to oral anticoagulation decreases the risk of systemic embolism or death among patients with prosthetic heart valves. The risk of major bleeding is increased with antiplatelet therapy. These results apply to patients with mechanical prosthetic valves or those with biological valves and indicators of high risk such as atrial fibrillation or prior thromboembolic events. The effectiveness and safety of low dose aspirin (100 mg daily) appears to be similar to higher dose aspirin and dipyridamole.

The number needed to harm: is it too optimistic?

The number needed to treat (NNT) to prevent one adverse outcome event is a useful measure of clinical trial results and represents the therapeutic effort required to realize a specific clinical benefit. With many therapies, there are both positive and negative consequences. Analogous to the NNT, there is the number needed to harm (NNH), which is the reciprocal of the absolute risk increase in situations where the experimental treatment harms more patients then the control treatment. The NNH is the number of patients who, if they received the experimental treatment, would lead to one additional person being harmed compared with patients who receive the control treatment. The NNH may, however, provide an optimistic measure of the true risks caused by therapy.

Evidence-based medicine and reteplase: inductive arguments over deductive reasoning.

Two trials of thrombolysis for acute myocardial infarction are contrasted and compared using a systematic approach developed for the interpretation of studies where equivalence is claimed. Reteplase has been compared with streptokinase in a true equivalence trial (International Joint Efficacy Comparison of Thrombolytics [INJECT] trial) and with tissue plasminogen activator in a failed superiority trial (Global Use of Strategies to Open Occluded Coronary Arteries [GUSTO] III). Important methodological distinctions and economic insights are highlighted. Using this approach one can conclude that the INJECT investigators have shown that reteplase is at least as effective as streptokinase and that the test for equivalence was satisfied. The point estimate of the treatment effect for the primary outcome event favours reteplase over streptokinase, and the confidence intervals essentially eliminate the possibility of streptokinase superiority. The GUSTO III primary outcome event, 30-day mortality, provides no convincing evidence that reteplase is equivalent to tissue plasminogen activator. Selective emphasis on one or two post hoc outcome event clusters, such as death and nonfatal stroke, or death and disabling stroke, provides some suggestive, but not conclusive, evidence for equivalence. Moreover, for some of the outcome events, and in particular the primary outcome event, the point estimate suggests that reteplase is, in fact, slightly less effective than tissue plasminogen activator.

Similar, the same or just not different: a guide for deciding whether treatments are clinically equivalent. [Dept. of Medicine, Division of Cardiology, Univ. of Western Ontario, London, Ontario].

Most clinical trials are designed to demonstrate superiority of one intervention over another. A less common goal is to show that any differences are sufficiently small to consider them interchangeable or clinically equivalent. Although similar to effectiveness trials, equivalence trials pose distinct methodological and interpretive challenges. Emphasis is placed on the distinction between a study designed to show 'equivalence' and a study designed to show 'superiority' that fails in its quest but in the end claims equivalence. Strategies used to minimize bias in superiority trials may actually increase the probability of showing no difference. Although there is no consensus as to the best statistical approach in describing the results of equivalence trials, an approach based on confidence intervals may be easier for clinicians to comprehend. A guide was developed to assist readers in determining whether claims of clinical equivalence are valid.

Potential cost effectiveness of tissue plasminogen activator among patients previously treated with streptokinase.

BACKGROUND: A major limitation of streptokinase is the development and persistence of problematic neutralizing antibodies that have the potential to limit the effectiveness of repeat streptokinase therapy. Accordingly, tissue-type plasminogen activator (t-PA) is frequently administered to patients with recurrent infarction presenting more than four days from previous treatment with streptokinase. OBJECTIVE: To explore the marginal cost effectiveness of the use of t-PA among patients with resistance to streptokinase. MATERIALS AND METHODS: A model was developed incorporating short term (five- to six-week) costs and mortality data for various thrombolytic strategies. It was assumed that streptokinase would be clinically ineffective when administered to streptokinase-resistant patients. Sensitivity analyses were performed varying the baseline mortality, the proportion of patients resistant to streptokinase and the absolute survival benefit of t-PA compared with streptokinase. RESULTS: In the absence of streptokinase resistance, streptokinase is a cost effective strategy for patients with suspected myocardial infarction, even when the expected mortality is low. In the presence of streptokinase resistance, the combination of streptokinase and acetylsalicylic acid is most cost effective when rates of resistance are low ($16,389 per short run survivor with 5% resistance versus $21,306 with 50% resistance). t-PA is a cost effective alternative when rates of resistance are high ($54,158 per short run survivor with 50% resistance) assuming a 1% absolute risk reduction in mortality. As the level of resistance decreases, however, t-PA becomes a less cost effective choice ($203,092 per short run survivor with 5% resistance). However, t-PA is always more cost effective in the presence of any streptokinase resistance than when it is administered for an index myocardial infarction. CONCLUSIONS: This analysis shows that using t-PA in patients previously treated with streptokinase is a cost effective strategy. t-PA becomes less cost effective as the percentage of patients with streptokinase resistance decreases, particularly when the absolute risk reduction favouring t-PA over streptokinase is small. Nevertheless, if the early mortality advantage is sustained, very favourable cost effectiveness ratios are attained with t-PA even when the risk of resistance is low. t-PA used in the presence of streptokinase resistance is always more cost effective than when it is used for a first myocardial infarction.

Access to an outpatient cardiology consultation in southwestern Ontario.

OBJECTIVE: To determine whether there were differences in waiting time for a consultation for a nonurgent cardiology problem among specialists in an academic centre compared with those in community practice. DESIGN: Cross-sectional telephone survey. SETTING: Southwestern Ontario. PARTICIPANTS: Academically affiliated and community-based specialists in cardiology or internal medicine with an interest in cardiology. OUTCOME MEASURE: Waiting period in weeks for outpatient consultation. RESULTS: Among community specialists, those with cardiology training had significantly longer waiting times than those without for nonurgent cardiology consultation (median 8.6 versus 3.8 weeks, P=0.0077). Waiting times for consultation were significantly longer for academic specialists than for those in community practice (median 9.1 versus 4.1 weeks, P=0.0013). Significantly longer waiting times exist in communities with a population greater than 100,000 (median 9.1 versus 4.0 weeks, P=0.0005). CONCLUSIONS: Waiting times for consultation for a nonurgent cardiology problem are long. Waiting times are longer for physicians with certification in cardiology, in the academic medical centre and in larger communities.

Precision and accuracy of the bedside examination in detecting an ejection fraction of less than 40% following acute myocardial infarction.

BACKGROUND: Left ventricular function is the most important determinant of prognosis following myocardial infarction. METHODS: A prospective analytical cohort study of 33 cardiac care unit survivors of acute myocardial infarction was performed to assess the accuracy, reproducibility and observer variation of the bedside Valsalva response in predicting an ejection fraction (EF) less than 40%. RESULTS: Agreement between physicians for the clinical Valsalva response was excellent (kappa coefficient 0.75), as was the comparison between physicians' clinical response to the Finapres (Ohmeda, USA) hemodynamic response (weighted kappa=0.85). The EF was significantly higher among patients with a normal Valsalva response (56.9%) than in patients with either an absent overshoot (48.4%) or a square wave (28.3%) response (P<0.001). Physicians were very accurate at estimating whether the EF was greater or less than 40%. In 40 of 66 situations, the clinicians were confident, based on the clinical examination and the Valsalva response, that the EF was either greater or less than 40%. In these situations, agreement (95.0%) and kappa (0.89) were both excellent. When all patients were considered, the degree of agreement (90.8%) and kappa (0.80) diminished slightly. A square wave response had poor sensitivity (37.5%) but excellent specificity (92.7%), whereas any abnormal response had excellent sensitivity (91.7%) but poor specificity (54.8%). CONCLUSION: Compared with many other aspects of the clinical examination, the bedside Valsalva manoeuvre has acceptable degrees of interobserver variability. A normal response tends to rule in an EF of greater than 40%, whereas a square wave response rules out an EF of greater than 40%. This simple bedside manoeuvre may be useful in predicting low EF following acute myocardial infarction.

The number remaining at risk: an adjunct to the number needed to treat.

Although the number of patients needed to treat (NNT) to prevent an adverse clinical event is of great clinical value to practising physicians, it is limited in that it fails to provide a measure of prognosis among patients not achieving benefit. For example, if the NNT is 100, what is likely to happen to the other 99? The number remaining at risk (NRR), which is an index that enhances the value of the NNT, is described. The NRR is the ratio of the residual event rate among treated patients and the absolute reduction in outcome events (NRR = experimental event rate [EER]/control event rate [CER]-EER), where EER and CER are the event rates among experimental and control groups, respectively. This index represents the number of events likely to occur among the NNT, or the odds of experiencing an adverse outcome event as opposed to deriving benefit from therapy. The NRR is a simple index that can easily be calculated from the published results of a clinical trial. As an adjunct to the NNT, it provides a measure of the impact of therapy and the average prognosis of remaining patients.

Anaphylactoid reaction during an infusion of recombinant tissue-type plasminogen activator for acute myocardial infarction.

Potentially life-threatening immediate hypersensitivity reactions are extremely rare among patients treated with thrombolytic agents for suspected acute myocardial infarction. A patient who developed a severe reaction during an infusion of recombinant tissue-type plasminogen activator is described. Potential causal mechanisms for the reaction could be related either to nonmedicinal additives or complement activation. Implications for treatment in the setting of acute myocardial infarction are discussed.

Mediastinal irradiation: A risk factor for atherosclerosis of the internal thoracic arteries.

Previous radiotherapy to the thorax is a risk factor for coronary artery disease. Patients with radiation-induced atherosclerosis tend to be young and frequently have lesions involving the coronary ostia and left anterior descending artery. Bypass is often the most suitable method of revascularization, and given the young age of the patient, arterial conduits would be considered superior to vein grafts. However, the internal thoracic arteries can lie within the radiation field and may not be free of atherosclerosis. A 40-year-old man who required coronary artery bypass grafting for multivessel coronary artery disease 11 years following radiotherapy for Hodgkin's lymphoma is reported. Preoperative angiography showed that the right internal thoracic artery had significant atherosclerosis and was unsuitable as a conduit.

PROTECT (Prospective Reinfarction Outcomes in the Thrombolytic Era Cardizem CD Trial): a randomized, double-blind clinical trial of diltiazem versus atenolol in secondary prophylaxis post non-Q wave myocardial infarction.

OBJECTIVE: To describe the rationale and design of the Prospective Reinfarction Outcomes in the Thrombolytic Era Cardizem CD Trial (PROTECT). DESIGN: A multicentre, randomized, double-blind, parallel-group comparison of once daily beta-therapy versus heart rate lowering calcium channel blocker therapy, in the reduction of one-year nonfatal reinfarction and cardiovascular death (combined primary end-point) initiated 24 to 96 h post non-Q wave myocardial infarction. SETTING: One hundred and twenty hospitals across Canada. PATIENTS: Over 7500 women and men aged 21 years or older with enzyme-confirmed non-Q wave infarction and without significant left ventricular systolic dysfunction will be recruited over two years. INTERVENTIONS: Once daily beta-blocker therapy (oral atenolol, 50 to 200 mg) versus once daily calcium channel blocker therapy (oral diltiazem 120 to 360 mg) with follow-up for up to three years. CONCLUSIONS: The PROTECT will be the largest all-Canadian cardiovascular trial to date and will compare two commonly prescribed agents for secondary prophylaxis following non-Q wave infarction. The scientific question addressed by the PROTECT is of major public health importance and the results of the study will directly affect current clinical practice.

Reducing bedrest following arterial puncture for coronary interventional procedures--impact on vascular complications: the BAC Trial.

BACKGROUND: The optimal time for ambulating patients following femoral arterial puncture for percutaneous coronary intervention is unknown. This study was designed to test the hypothesis that reducing time to ambulation from 6 hours to 2 hours would not increase vascular complications. METHODS: In this randomized, controlled, single-center trial, patients were randomly assigned to receive either 2, 4 or 6 hours (control group) of bedrest after hemostasis was achieved at the femoral arterial puncture site. A total of 354 patients, enrolled from March 1997 to October 1998, participated in the study with 299 completing the full protocol. The primary endpoint was the incidence of vascular complications and any resulting interventions or outcomes including surgery, blood transfusion, prolonged length of stay or ultrasound compression. RESULTS: The 2 hour and 4 hour experimental groups were comprised of 99 patients each, while the 6 hour control group was comprised of 101 patients. There were no differences in vascular complications between the groups. A subgroup analysis of patients who received abciximab (n = 43) did not reveal any differences between groups. Only one patient developed a pseudoaneurysm (p = 0.36), requiring surgical repair and a prolonged length of stay. CONCLUSIONS: Patients undergoing femoral arterial puncture for coronary interventional procedures can safely ambulate 2 hours after hemostasis of the puncture site. Patients receiving abciximab as part of their coronary procedure may be able to ambulate as early as 2 hours following hemostasis.

Management of the patient following coronary thrombolysis.

Myocardial salvage can be maximized by the early institution of thrombolytic therapy and aspirin. Certain patients may benefit from the administration of intravenous heparin, beta blockers, or nitroglycerin. The routine use of percutaneous transluminal coronary angioplasty (PTCA) or calcium-channel blockers does not appear to be warranted. Recurrent myocardial ischemia should be vigorously treated with medical therapy and there may be value in cardiac catheterization, followed by PTCA or bypass surgery, depending upon the extent of myocardium at risk and the underlying coronary anatomy. Long-term morbidity and mortality may be reduced by instituting aspirin and beta blockers as well as by modifying risk factors. There is no evidence for the long-term benefit from any calcium-channel blocker. Oral anticoagulation may be warranted in those patients with a mural thrombus, congestive heart failure, or atrial fibrillation. ACE inhibitors may be of value in the presence of left ventricular dysfunction and certainly in the presence of symptomatic congestive heart failure. Antiarrhythmic therapy is generally indicated only for symptomatic or life-threatening arrhythmias. Residual myocardial ischemia should be sought by exercise testing, and those patients with poor exercise tolerance generally warrant cardiac catheterization in consideration for revascularization.