Measuring and treating serum lipids in patients in a chest pain observation unit.

We evaluated opportunities to initiate statin therapy in 574 consecutive subjects admitted to a chest pain observation unit (CPOU). Ten-year Framingham risk scores were retrospectively calculated for all patients according to the National Cholesterol Education Program and Adult Treatment Panel III 2001 recommendations. Subjects were then stratified according to (1) recommendations for initiation of a lipid-lowering medication and (2) whether they received lipid-lowering drug therapy at discharge. Of 574 subjects, we excluded 50 with previously established coronary heart disease or who were already taking a statin medication on presentation, 23 with missing data, and 80 who did not have a low-density lipoprotein (LDL) measurement at admission. Of the remaining 421 subjects, the mean age was 47 years, 40% were men, 57% were white, 31% had hypertension, 27% were current smokers, and 6% had diabetes. Ten-year risk calculation classified 47% (n=199) at low risk (<2 risk factors), 32% (n=134) at moderate risk (>or=2 risk factors and <10% risk), 11% (n=48) at moderate-high risk (10% to 20% risk), and 10% (n=40) at high risk (>20% risk). Of the entire cohort, 23% of subjects (n=96) had hypercholesterolemia, of which 52% (n=50) met indications for initiation of lipid-lowering medication. Only 6% of patients with an indication for treatment (n=3) were prescribed a lipid-lowering medication on discharge, leaving 94% (n=47) untreated for their hypercholesterolemia. In conclusion, patients admitted to a CPOU have a high prevalence of hypercholesterolemia, and therefore, an increased long-term risk for cardiovascular events. In addition to their primary role, CPOUs should focus on primary prevention and reduction of long-term risk.

A prospective randomized clinical trial of the use of fluoroscopy in obtaining femoral arterial access.

BACKGROUND: There is no consensus on the utility of fluoroscopy in obtaining common femoral artery (CFA) access. METHODS: Patients weighing < 136.4 kg (300 lbs) with palpable femoral pulses undergoing coronary angiography were randomized to arterial access with or without the use of fluoroscopy (using the center of the femoral head as the optimal site to enter the artery). RESULTS: 208 patients were enrolled with 110 randomized to the palpation group and 98 were randomized to the palpation +fluoroscopy group. Mean age (+/- SD) was 60 +/- 11 years, 61% were male, 35% had diabetes, and 40% had a body mass index (BMI) > 30 kg/m(2). Clinical characteristics and procedural factors were similar among the two groups with the exception that fewer needle passes were required and access was achieved faster in the palpation group. Arterial puncture over the femoral head occurred in 91% of the palpation group versus 95% of the palpation + fluoroscopy group (p = 0.27). Successful CFA puncture occurred in 85% of the palpation group versus 90% of the palpation + fluoroscopy group (p = 0.49). Cannulation of the external iliac artery occurred in 1 patient in each group, whereas arterial puncture distal to the CFA bifurcation occurred in 16 (15%) of the palpation group and in 9 (9%) of the palpation + fluoroscopy group (p = 0.33). CONCLUSION: In this single-center, randomized trial, the use of fluoroscopy did not increase the probability of arterial puncture over the femoral head or the rate of successful CFA cannulation.