Visual estimation of shoulder posture: accuracy and reliability across five planes of motion

Background: Visual estimation is still widely used by physiotherapists in clinical practice. The accuracy and reliability of visual estimation are under question and vary with the joint being evaluated. The utility of using visual estimation to evaluate shoulder angular posture is inconclusive and has yet to be evaluated across a comprehensive range of planes and postures.

Objective: The purpose of this observational, cross-sectional study was to determine whether visual estimation is an accurate and reliable procedure for determining shoulder angular postures in a range of shoulder motions.

Methods: Sixty-three physical therapy students viewed digital photographs of an asymptomatic volunteer to visually estimate degrees of arm abduction, flexion, extension, internal rotation, and external rotation. Six photographs from each plane of movement were shown, at positions spanning the available range of motion, and participants were asked to estimate the angular posture. Estimates were averaged, and errors from computer measurements were calculated. Differences between estimates and measurements were determined with t-tests.

Results: The overall accuracy of the visual estimates is considered poor to fair. Root mean square errors were reasonable, from 5° to 17°, but the 95% spread of the data reached a maximum of 53°. Estimates were most accurate at the abduction and flexion postures closest to 90°. Most estimates for extension were underestimated, while more internal rotation estimates were overestimated. Reliability ranged from poor to fair (0.12–0.63).

Conclusions: Using visual estimation to evaluate shoulder planar postures results in a wide range of error. Physiotherapy students should be encouraged to use more objective measurement methods.     

Role of Antiischemic Agents in the Management of Non‐ST Elevation Acute Coronary Syndrome (NSTE‐ACS)

Non‐ST elevation acute coronary syndrome (NSTE‐ACS) is the commonest acute presentation of coronary artery disease (CAD). Mortality and morbidity of the condition has improved substantially over the last few decades as a result of the cumulative effect of multiple interventions acting via different mechanisms. Despite a significant increase in the rate of coronary intervention, medical therapy continues to retain a central role in the treatment of NSTE‐ACS particularly in frail patients where revascularization is inappropriate or when it is incomplete. Several antiischemic agents have been used in the treatment of the condition. Beta blockers are often the first‐line choice with calcium channel blockers and nitrates being used as an alternative when beta blockers are contraindicated, or as an addition to achieve optimal symptom control. Newer agents, such as nicorandil, ivabradine, and ranolazine have also been used in refractory cases. Although most of these agents have been extensively studied in large randomized controlled trials in patients with stable CAD or ST elevation acute coronary syndrome (STE‐ACS), the evidence supporting their use in NSTE‐ACS is less clear cut. In this article, we review various drugs available for controlling ischemia and the latest evidence in support of their use in NSTE‐ACS.     

Prognostic Implications of Declining Hemoglobin Content in Patients Hospitalized With Acute Coronary Syndromes

BackgroundContemporary definitions of bleeding endpoints are restricted mostly to clinically overt events. Whether hemoglobin drop per se, with or without overt bleeding, adversely affects the prognosis of patients with acute coronary syndrome (ACS) remains unclear.ObjectivesThe aim of this study was to examine in the MATRIX (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) trial the incidence, predictors, and prognostic implications of in-hospital hemoglobin drop in patients with ACS managed invasively stratified by the presence of in-hospital bleeding.MethodsPatients were categorized by the presence and amount of in-hospital hemoglobin drop on the basis of baseline and nadir hemoglobin values and further stratified by the occurrence of adjudicated in-hospital bleeding. Hemoglobin drop was defined as minimal (<3 g/dl), minor (≥3 and <5 g/dl), or major (≥5 g/dl). Using multivariate Cox regression, we modeled the association between hemoglobin drop and mortality in patients with and without overt bleeding.ResultsAmong 7,781 patients alive 24 h after randomization with available hemoglobin data, 6,504 patients (83.6%) had hemoglobin drop, of whom 5,756 (88.5%) did not have overt bleeding and 748 (11.5%) had overt bleeding. Among patients without overt bleeding, minor (hazard ratio [HR]: 2.37; 95% confidence interval [CI]: 1.32 to 4.24; p = 0.004) and major (HR: 2.58; 95% CI: 0.98 to 6.78; p = 0.054) hemoglobin drop were independently associated with higher 1-year mortality. Among patients with overt bleeding, the association of minor and major hemoglobin drop with 1-year mortality was directionally similar but had wider CIs (minor: HR: 3.53 [95% CI: 1.06 to 11.79]; major: HR: 13.32 [95% CI: 3.01 to 58.98]).ConclusionsAmong patients with ACS managed invasively, in-hospital hemoglobin drop ≥3 g/dl, even in the absence of overt bleeding, is common and is independently associated with increased risk for 1-year mortality. (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox; NCT01433627)     

Long-Term Outcomes of Complete Revascularization With Percutaneous Coronary Intervention in Acute Coronary Syndromes

ObjectivesThe aim of this study was to evaluate the long-term outcomes of patients with acute coronary syndromes (ACS) with multivessel disease undergoing percutaneous coronary intervention (PCI).BackgroundControversy exists regarding the benefit of multivessel PCI across the spectrum of ACS.MethodsA total of 9,094 patients with ACS and multivessel disease (≥70% stenosis in 2 or more major epicardial vessels) undergoing PCI from the Alberta COAPT (Contemporary Acute Coronary Syndrome Patients Invasive Treatment Strategies) registry (April 1, 2007, to March 31, 2013) were reviewed. Comparisons were made between patients who underwent complete revascularization and those with incomplete revascularization. Complete revascularization was defined as multivessel PCI with a residual angiographic jeopardy score ≤10%. Associations between revascularization status and all-cause death or new myocardial infarction (primary composite endpoint) and all-cause death, new myocardial infarction, or repeat revascularization (secondary composite endpoint) were evaluated.ResultsOf the study cohort, 66.0% underwent complete revascularization. Compared with incomplete revascularization, the primary composite endpoint occurred less frequently with complete revascularization (event rate within 5 years 15.4% vs. 22.2%; inverse probability-weighted hazard ratio [IPW-HR]: 0.78; 95% confidence interval [CI]: 0.73 to 0.84; p < 0.0001). The secondary composite endpoint was less likely to occur with complete revascularization (event rate within 5 years 23.3% vs. 37.5%; IPW-HR: 0.61; 95% CI: 0.58 to 0.65; p < 0.0001). Complete revascularization was associated with a reduction in all-cause death (IPW-HR: 0.79; 95% CI: 0.73 to 0.86; p = 0.0004), new myocardial infarction (IPW-HR: 0.76; 95% CI: 0.69 to 0.84; p < 0.0001), and repeat revascularization (IPW-HR: 0.53; 95% CI: 0.49 to 0.57; p < 0.0001).ConclusionsResults from this large contemporary registry of patients with ACS and PCI for multivessel disease suggest that complete revascularization occurs commonly and is associated with improved clinical outcomes (including survival) within 5 years.     

心肌缺血预适应对急性心肌梗死ST段形态的影响

目的探讨心肌缺血预适应对急性心肌梗死ST段形态的影响。方法103例初发急性心肌梗死按入院时梗死相关导联ST段抬高形态分为凹面向上组和凸面向上组,以梗死发生前24h至少出现1次典型心绞痛症状为标准,比较两组频率。结果梗死前24h内出现心绞痛凹面向上组34例(73.91%),凸面向上组14例(24.56%);无心绞痛凹面向上组12例(26.09%),凸面向上组43例(75.44%)。两组差异均有非常显著性意义(P<0.01)。结论心肌缺血预适应是急性心肌梗死ST段凹面向上抬高的机制之一,根据心电图ST段凹面抬高推断其梗死前存在缺血预适应及由此产生的心肌保护作用对临床有重要意义。     

Prognostic value of troponins in patients with non-ST-segment elevation acute coronary syndromes and chronic kidney disease

BACKGROUND: The prognostic value of cardiac troponins (cTn) in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) and chronic kidney disease (CKD) is debated. HYPOTHESIS: We tested the performance of cTnI and cTnT for risk stratification in patients with CKD and evaluated the prognostic significance of cTnI and cTnT elevations by their magnitude across the range of CKD severity. METHODS: We examined correlations among cTn elevation, CKD, and in-hospital mortality in 31,586 high-risk patients with NSTE ACS included in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines initiative (CRUSADE). Cardiac tropinins I and T levels were categorized as ratios of each site's upper limit of normal (ULN) for myocardial necrosis: normal (cTn ratio < or =1 x ULN), mild (cTn ratio > 1-3 x ULN), and major (cTn ratio > 3 x ULN) elevation. Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated Modification of Diet in Renal Disease equation. Stages of CKD were categorized as normal to mild (eGFR > 60 mL/min), moderate (eGFR 30-60 mL/min), or severe (eGFR < 30 mL/min). RESULTS: Mortality increased more steeply across CKD stages (2.0%-12.9%) than across cTn ratio categories (2.7%-5.4%). In normal or mild CKD, mortality was low regardless of cTn elevations. In moderate CKD, mortality increased incrementally with cTnI (3.3% versus 5.4% versus 7.4%) and cTnT (3.7% versus 5.3% versus 7.3%) elevation. Among severe CKD patients, only major cTn elevations further distinguished risk (cTnI: 10.1% versus 9.7% versus 14.6%; cTnT: 7.0% versus 5.7% versus 14.0%). CONCLUSIONS: In patients with CKD, cTnI and cTnT perform equally in differentiating short-term prognosis following NSTE ACS; however, the prognostic impact of cTn is dependent upon the degree of CKD severity.     

Improvement in door-to-balloon times in management of acute ST-segment elevation myocardial infarction STEMI through the initiation of 'Code AMI'

Background: ST‐segment elevation myocardial infarction (STEMI) mandates rapid percutaneous coronary intervention (PCI) for optimal outcomes. The aim of this study was to assess our hospital practice for managing acute STEMI, identify processes associated with time delays, instrument changes to our acute STEMI management protocol and assess their effectiveness for improving our door‐to‐balloon time. Methods: We aimed to achieve this through the establishment of a quality improvement programme involving the cardiology and emergency departments. We analysed consecutive patients presenting with STEMI (April to September 2005 (group A) and the corresponding period in 2006 (group B), and compared patients presenting ‘in hours’ (0700 hours to 1800 hours (Monday to Friday)) versus ‘out of hours’ (all other times including public holidays). Results: In group A, 38 patients presented with a STEMI. Assessing time‐to‐treatment analysis, the median door to balloon time for primary PCI was significantly greater for ‘out of hours’ than ‘in hours’ (120 vs 67 min). The greatest time delay to PCI was from the PCI decision time to catheter laboratory arrival. Local changes were implemented to improve ‘out of hours’ times, including initiation of ‘Code AMI’. There were 59 patients in group B. We found that our changes led to a 29% improvement in ‘out of hours’ door‐to‐balloon time (median time 82 min, P = 0.005) with 69% being managed ≤90 min (P = 0.049) (group B). Conclusion: We have shown that ongoing review through a quality improvement programme improves door‐to‐balloon times, which is integral in the optimal management of patients with acute STEMI treated with primary PCI.     

重组人尿激酶原（普佑克）治疗急性ST段抬高型心肌梗死52例探讨

目的：探讨重组人尿激酶原治疗急性ST段抬高型心肌梗死的疗效及安全性。方法选择急性ST段抬高型心肌梗死患者52例,根据随机数字表法将患者分为尿激酶原组和同瑞替普酶组,每组各26例。同瑞替普酶组给予同瑞替普酶治疗,重组尿激酶原组采用重组尿激酶原治疗。比较两组给药后不同时间点的纤溶酶、纤溶酶原、纤维蛋白原水平变化、冠状动脉再开通情况及心脏事件、出血程度情况。结果两组纤溶酶在给药0 h、24 h、48 h差异无统计学意义(P>0.05),但给药2 h时,重组尿激酶原组纤溶酶明显高于同瑞替普酶组(P<0.05);两组纤溶酶原、纤维蛋白原在给药0 h、48 h差异无统计学意义(P>0.05),但给药2 h、24 h时,重组尿激酶原组纤溶酶原、纤维蛋白原明显高于同瑞替普酶组(P<0.05)。重组尿激酶原组的心脏事件发生率明显低于同瑞替普酶组,出血程度明显轻于同瑞替普酶组(P<0.05)。重组尿激酶原组的再通率和完全再通率明显高于同瑞替普酶组(P<0.05)。结论重组尿激酶原对急性ST段抬高型心肌梗死患者的凝血和纤溶系统影响较小,确保了溶栓效果,提高了再通和完全再通率,减少了心脏事件的发生风险及减轻再出血程度,故具有较好的临床适用性。     

ST-segment elevation due to myocardial invasion of lung cancer mimicking ST elevation myocardial infarction: A case report

Introduction:When a cancer patient presents with ST-segment elevation on an electrocardiogram (ECG), several causes including acute myocardial infarction (MI) should be considered. Myocardial metastasis is one of the rare causes of ST-segment elevation in cancer patients and its clinical silence makes it difficult to diagnose.Patient concerns:A 78-year-old man with lung cancer presented to the emergency room for chest pain. ECG revealed ST-segment elevation in inferior and lateral leads.Interventions:After emergent coronary angiography, percutaneous coronary intervention (PCI) on proximal right coronary artery was performed.Outcomes:Even 7 days after PCI, ST-segment elevation in inferior and lateral leads still existed. Cardiac markers continued to be within the normal range.Diagnosis:We found evidence of metastasis of lung cancer on the inferolateral wall of the myocardium by trans thoracic echocardiogram and positron emission tomography (PET)/computed tomography (CT). We diagnosed myocardial metastasis as the cause of ST-segment elevation in the patient.Conclusion:Myocardial metastasis is one of the differential diagnosis of ST-segment elevation in cancer patients. Periodic ECG is necessary for lung cancer patients and rapid cardiac work-up is recommended when ST-segment elevation is newly discovered.     

Clinical impact of complete atrioventricular block in patients with ST‐segment elevation myocardial infarction

Complete atrioventricular block (CAVB) is a common complication of ST‐segment elevation myocardial infarction (STEMI). Although STEMI patients complicated with CAVB had a higher mortality in the thrombolytic era, little is known about the impact of CAVB on STEMI patients who underwent primary percutaneous coronary intervention (PCI). The study aimed at evaluating the clinical impact of CAVB on STEMI patients in the primary PCI era. We consecutively enrolled 1295 STEMI patients undergoing primary PCI within 24 hours from onset. Patients were divided into two groups according to the infarct location: anterior STEMI (n = 640) and nonanterior STEMI (n = 655). The outcomes were all‐cause death and major adverse cardiocerebrovascular events (MACCE) with a median follow‐up period of 3.8 (1.7–6.6) years. Eighty‐one patients (6.3%) developed CAVB. The incidence of CAVB was lower in anterior STEMI patients than in nonanterior STEMI (1.7% vs 10.7%, p < .05). Anterior STEMI patients with CAVB had a higher incidence of all‐cause deaths (82% vs 20%, p < .05) and MACCE (82% vs 25%, p < .05) than those without CAVB. Although higher incidence of all‐cause deaths was found more in nonanterior STEMI patients with CAVB compared with those without CAVB (30% vs 18%, p < .05), there was no significant difference in the incidence of MACCE (24% vs 19%). Multivariate analysis showed that CAVB was an independent predictor for all‐cause mortality and MACCE in anterior STEMI patients, but not in nonanterior STEMI. CAVB is rare in anterior STEMI patients, but remains a poor prognostic complication even in the primary PCI era.