A handful of people with pulmonary embolism have absolute contraindications to anticoagulation. Authors here describe these as: Any prior intracranial hemorrhage, known structural intracranial cerebrovascular disease (eg, arteriovenous malformation), known malignant intracranial neoplasm, ischemic stroke within 3 months, suspected aortic dissection, active bleeding or bleeding diathesis, recent surgery encroaching on the spinal canal or brain, [… read more]
If you spend your nights lying awake worrying about having a heart attack, you’re entirely justified. But you’re probably just making it more likely. Lars Laugsand et al followed 52,610 Norwegian people for 11 years after the subjects completed an initial survey (investigators can do this in Norway, since they’ve got everyone’s health records in [… read more]
Faced with steadily rising costs of medical care insurance, more and more U.S. employers are insisting that smokers pay a higher share of the premiums of their employer-sponsored insurance, according to a Towers Watson survey of 248 businesses. 19% of companies with >1,000 employees have increased smokers’ share of medical care insurance premiums, double the rate from [… read more]
According to compelling new data, you can win the genetic lottery and live healthy all your life, and you’ll still be more likely to die from your first heart attack than the diabetic guy in the next bed who keeps going outside to smoke to relieve his chest pain. But you’ll at least have had more time [… read more]
Intracranial hemorrhage is a subject neuro-intensivists spend years learning about and refining their knowledge and skills on. A few key points: Myocardial “stunning” with depressed ejection fraction and pulmonary edema should be expected, due to a form of tako-tsubo cardiomyopathy, most commonly in subarachnoid hemorrhage. It’s not due to ischemia and gets better over weeks. [… read more]
Thanks to defibrillators, burly-armed EMTs, speedier cardiac revascularization, and induced hypothermia, the mortality rates after ventricular tachycardia or fibrillation have improved markedly for both in- and out-of-hospital cardiac arrests. But mortality rates after PEA and asystole remain stubbornly steady, seemingly resistant to any of the above interventions. Background: People suffering cardiac arrest in an ICU have the advantage [… read more]
October’s Seminars in Respiratory & Critical Care Medicine brings you 110 pages and 11 articles on organ failure in the intensive care unit, with articles including: Organ failure scoring and predictive models Cardiac alterations due to organ failure The microcirculation as a therapeutic target in shock Immuologic derangements in organ failure Acute lung failure Cardiogenic [… read more]
More than 40 small, middling-quality studies (n~80, some randomized) showing inconsistent results as to whether antioxidant therapy with acetylcysteine or other drugs reduces the risk for contrast nephropathy / acute kidney injury after angiography or CT-angiography. A 2008 meta-analysis concluded Mucomyst was helpful, reducing risk of nephropathy by almost 40% vs saline alone. However, the authors noted [… read more]
The new coumadin-killers, direct thrombin inhibitor dabigatran (approved in the U.S.) and direct factor Xa inhibitor rivaroxaban (coming soon) could usher in an awesome new era of anticoagulation, without warfarin’s requirements of cumbersome monitoring and annoying in-hospital titrations. But what happens when patients taking these drugs bleed, or need emergency surgery? Fresh-frozen plasma doesn’t work. [… read more]
Here’s a free “head-to-head” discussion with arguments for and against implementation of routine mild hypothermia for all patients with out-of-hospital cardiac arrest. The benefits of hypothermia after out-of-hospital ventricular fibrillation cardiac arrests are reasonably well-established, and multiple society guidelines (SCCM’s, AHA’s) advocate the practice. The question is whether to induce mild hypothermia / targeted temperature management in all [… read more]
Increasing urine output should reduce the risk for contrast nephropathy, as should hustling contrast metal past vulnerable Na-K-Cl transporters using loop diuretics. However, furosemide alone increases the risk for contrast nephropathy. Some hypothesized that was due to diuretic-induced hypovolemia. Briguori et al report results of REMEDIAL-II. They randomized ~300 patients at very high risk for [… read more]
Enriquez et al analyzed data from the NHLBI Dynamic Registry, comparing 860 people with COPD to 10,048 without who underwent percutaneous coronary intervention between 1999-2006. Their main findings: COPD patients were sicker and had worse outcomes. Demographically, they had a higher rate of diabetes, slightly more lesions (3.2 vs. 3.0), and slightly lower ejection fractions. Only [… read more]
O’Connor et al report results of a randomized trial of 7,141 people with acute decompensated heart failure who got nesiritide or placebo in addition to standard care. To sum up, nesiritide didn’t seem to do much of anything at all (for dyspnea, risk of rehospitalization or death, or any other endpoint). NEJM 2011;365:32-43.
Planer et al randomized 151 smokers admitted for acute coronary syndrome to receive either bupropion sustained-release or placebo for 8 weeks. There was no difference in abstinence rates at 3, 6, or 12 months. Those who had an invasive procedure during hospitalization were 4 times more likely to quit, though. (n=151) Arch Intern Med 2011;171:1055-1060.
Parent et al report that among 398 people with sickle cell disease, the prevalence of pulmonary hypertension seemed to be 27% by echocardiography. By right heart catheterization, it was 6%. NEJM 2011;365:44-53.
Kuniyoshi et al prospectively observed people admitted to Mayo for myocardial infarction, performing polysomnography and measuring flow-mediated dilation in their brachial arteries. A whopping 69% (45 of 64) were found to have obstructive sleep apnea. Those with moderate to severe OSA had poorer arterial responsiveness, a surrogate marker for subsequent cardiovascular risk, compared to people [… read more]
Brown et al report that 21% of patients in the REVEAL registry were diagnosed with IPAH >2 years after the onset of symptoms. Younger patients, and those picking up a diagnosis of obstructive lung disease or sleep apnea along the way, were more likely to have a delay in diagnosis. CHEST 2011;140:19-26.
3% saline infusions have become standard care for increased intracranial pressure at many centers, based on mostly anecdotal evidence. Hauer et al looked retrospectively at 100 patients receiving 3% saline for severe stroke in 2008-2009 (intracerebral hemorrhage, subarachnoid hemorrhage, or ischemic) and compared them to 115 historical controls, 2007-2008 with “equal” underlying disease. Hypertonic saline [… read more]
Improving survival after out-of-hospital cardiac arrest: AHA Consensus Statement. Neumar RW et al. Circulation 2011;123:2898-2910. FREE FULL TEXT. Guideline. Review.
Peacock et al randomized 226 people in 13 US EDs to either IV nicardipine or IV labetalol for hypertensive emergency (SBP ~215). More patients receiving nicardipine achieving their target BP range within 30 minutes (92% vs. 83%). (n=226) Critical Care 2011;15:R157. FREE FULL TEXT