Evaluating the obtunded patient after cardiac surgery: The role of continuous electroencephalography

Purpose

This prospective study was designed to evaluate the role of continuous electroencephalography (EEG) in the management of adult patients with neurological dysfunction early after cardiac surgery.

Materials and Methods

Seven hundred twenty-three patients undergoing cardiac surgery between December 2010 and June 2011 were divided into 2 groups based on the presence or absence of post-operative neurological dysfunction. All patients with neurological dysfunction underwent continuous EEG.

Results

Neurological dysfunction was diagnosed in 12 patients (1.7%), of whom 5 (42%) did not regain consciousness after surgery, 4 (33%) had a clinical event suspicious for seizure and 3 (25%) had neurological deficits. Continuous EEG showed that 2 of the 5 patients who failed to regain consciousness, without clinical signs of seizures, were in electrographic non-convulsive focal status epilepticus. Periodic discharges were present in the continuous EEGs of 3 patients. Three additional patients (25%) had abnormal movements that continuous EEG demonstrated was not due to seizure activity.

Conclusions

Non-convulsive status epilepticus may be an under-recognized cause of obtundation early after cardiac surgery. Continuous EEG monitoring is a non-invasive test that can identify patients that may benefit from anti-epileptic medication. Larger comparative studies are required to establish whether this leads to significant improvements in patient outcomes.     

Cost-effectiveness analysis of ED decision making in patients with non–high-risk heart failure

Background

The ED disposition of patients with non–high-risk acute decompensated heart failure (ADHF) is challenging. To help address this problem, we investigated the cost-effectiveness of different ED disposition strategies.

Methods

We constructed a decision analytic model evaluating the cost-effectiveness of 3 possible ED ADHF disposition strategies in a 60-year-old man: (1) discharge home from the ED; (2) observation unit (OU) admission; (3) inpatient admission. Base case patients had no high-risk features. We used Medicare costs and the national physician fee schedule to capture ED, OU, and hospital costs, including costs of complications and death. All analyses were conducted using Decision Maker software (University of Medicine and Dentistry of New Jersey, Newark, NJ).

Results

Compared to ED discharge, OU admission had a reasonable marginal cost-effectiveness ratio ($44 249/quality adjusted life year), whereas hospital admission had an unacceptably high marginal cost-effectiveness ratio ($684 101/quality adjusted life year). Sensitivity analyses demonstrated that as the risk of early (within 5 days) and late (within 30 days) readmission exceeded 36% and 74%, respectively, in those discharged from the ED, OU admission became less costly and more effective than ED discharge. Similarly, an increase in relative risk of both early and late death in those discharged from the ED improves the marginal cost-effectiveness ratio of OU admission. Finally, as postdischarge event rates increase in those discharged from the OU, hospital admission became more cost-effective.

Conclusion

Observation unit admission for patients with non–high-risk ADHF has a societally acceptable marginal cost-effectiveness ratio compared to ED discharge. However, as ED and OU discharge event rates increase, hospital admission becomes the more cost-effective strategy.     

Myocardial dysfunction during H1N1 influenza infection

Purpose

The purpose of the study is to evaluate the incidence and hemodynamic consequences of right ventricular (RV) and left ventricular (LV) dysfunction in critically ill patients with H1N1 infection.

Patients and methods

This is a retrospective analysis of all patients admitted to the intensive care unit of an academic hospital between October 2009 and March 2011 with severe H1N1 infection. Hemodynamic measurements and respiratory conditions were noted daily during the intensive care unit stay.

Results

Forty-six patients were admitted with severe H1N1 infection. Echocardiography was obtained in 39 patients on admission: 28 (72%) had abnormal ventricular function, of whom 13 (46%) had isolated LV abnormalities, 11 (39%) had isolated RV dysfunction, and 4 (14%) had biventricular dysfunction. Echocardiography was repeated in 19 of the 39 patients during their hospitalization: RV function tended to worsen with time, but LV function tended to normalize. The ventricular abnormalities were not associated with history, severity of the respiratory failure, or hemodynamic status. However, patients with ventricular dysfunction needed more aggressive therapy, including more frequent use of vasopressor and inotropic agents and of rescue ventilatory strategies, such as inhaled nitric oxide, prone positioning, and extracorporeal membrane oxygenation.

Conclusions

These observations emphasize the high incidence of cardiac dysfunction in patients with H1N1 influenza infections.     

Do Hemolyzed Potassium Specimens Need to be Repeated?

Background

In the emergency department (ED), hyperkalemia in the presence of hemolysis is common. Elevated hemolyzed potassium levels are often repeated by emergency physicians to confirm pseudohyperkalemia and to exclude a life-threatening true hyperkalemia.

Objectives

We hypothesize that in patients with a normal renal function, elevated hemolyzed potassium, and normal electrocardiogram (ECG), there may not be a need for further treatment or repeat testing and increased length of stay.

Methods

Data were prospectively enrolled patients presenting to the ED from July 2011 to February 2012. All adult subjects who had a hemolyzed potassium level ≥ 5.5 mEq/dL underwent a repeat potassium level and ECG. The incidence of true hyperkalemia in this population was measured.

Results

A total of 45 patients were enrolled. The overall median age was 52 years (range 25–83 years); 22 were female (49%). In patients with hyperkalemia on initial blood draw and glomerular filtration rate (GFR) ≥ 60 (n = 45), the negative predictive value was 97.8% (95% confidence interval [CI] 88.2–99.9%). When patients had hyperkalemia on initial blood draw, GFR ≥ 60, and a normal ECG (n = 42), the negative predictive value was 100% (95% CI 93.1–100%).

Conclusions

In the setting of hemolysis, GFR ≥ 60 mL/min in conjunction with a normal ECG is a reliable predictor of pseudohyperkalemia and may eliminate the need for repeat testing. In patients with a normal GFR who are otherwise deemed safe for discharge, our results indicate there is no need for repeat testing.     

Cardiac Rehabilitation and Outcome in Stable Outpatients With Recent Myocardial Infarction

Objective

To compare the mortality rate and the rate of subsequent ischemic events (myocardial infarction [MI], ischemic stroke, or limb amputation) in patients with recent MI according to the use of cardiac rehabilitation or no rehabilitation.

Design

Longitudinal observational study.

Setting

Ongoing registry of outpatients.

Participants

Patients (N=1043) with recent acute MI were recruited; of these, 521 (50%) participated in cardiac rehabilitation.

Interventions

Not applicable.

Main Outcome Measures

Subsequent ischemic events and mortality rates were registered.

Results

Over a mean follow-up of 18 months, 50 patients (4.8%) died and 49 (4.7%) developed 52 subsequent ischemic events (MI: n=43, ischemic stroke: n=6, limb amputation: n=3). Both the mortality rate (.16 vs 5.57 deaths per 100 patient-years; rate ratio=.03; 95% confidence interval [CI], 0.0–0.1]) and the rate of subsequent ischemic events (1.65 vs 4.54 events per 100 patient-years; rate ratio=0.4; 95% CI, 0.2–0.7) were significantly lower in cardiac rehabilitation participants than in nonparticipants. Multivariate analysis confirmed that patients in cardiac rehabilitation had a significantly lower risk of death (hazard ratio=.08; 95% CI, .01–.63; P=.016) and a nonsignificant lower risk of subsequent ischemic events (hazard ratio=.65; 95% CI, .30–1.42).

Conclusions

The use of cardiac rehabilitation in patients with recent MI was independently associated with a significant decrease in the mortality rate and a nonsignificant decrease in the rate of subsequent ischemic events.     

Persistent organ dysfunction after severe sepsis: A systematic review

Objective

Sepsis is a prevalent disease with high mortality. Survivors of sepsis often suffer significant resultant morbidity, including organ dysfunction. However, little is known about persistent or long-term organ dysfunction in this patient population. Our objective was to systematically review original research studies evaluating organ-specific outcomes at 28 days or greater in patients surviving severe sepsis.

Methods

We performed a systematic review of studies reporting organ-specific outcomes at 28 days or greater in survivors of severe sepsis.

Results

We identified 1,173 articles and five met our inclusion criteria. No study reported on organ dysfunction at greater than 30 days. Two studies contributed the majority of patients and had consistent rates of 1 month organ dysfunction for adult respiratory distress syndrome (ARDS) (8%-9%), renal (7%-8%), hepatic (3%-7%), and central nervous system (2%-5%). Another study reported higher rates of dysfunction for pulmonary (non-ARDS and ARDS), hepatic and renal but similar rates for central nervous system and disseminated intravascular coagulation when compared to the first two studies. The most recent study had the highest rates of dysfunction (> 47%) across all organ systems. For organ failure resolution the rates were highly variable.

Conclusions

Our review found variable rates of organ dysfunction at 1 month after severe sepsis. Future studies should attempt to characterize organ dysfunction at greater than 1 month after an acute severe sepsis episode to determine the true prevalence long-term organ dysfunction and treatments for prevention. Additionally, standardized objective measures of organ dysfunction are needed so that future studies can be directly compared.     

Can the degree of hydronephrosis on ultrasound predict kidney stone size?

Objective

The aim of the study was to determine if the degree of hydronephrosis on focused emergency renal ultrasound correlates with kidney stone size on computed tomography.

Methods

A retrospective study was performed on all adult patients in the emergency department who had a focused emergency renal ultrasound and ureterolithiasis on noncontrast computed tomography. Severity of hydronephrosis was determined by the performing physician. Ureteral stone size was grouped into 5 mm or less and larger than 5 mm based on likelihood of spontaneous passage.

Results

One hundred seventy-seven ultrasound scans were performed on patients with ureteral calculi. When dichotomized using test characteristic analysis, patients with none or mild hydronephrosis (72.9%) were less likely to have ureteral calculi larger than 5 mm than those with moderate or severe hydronephrosis (12.4% vs 35.4%; P < .001) with a negative predictive value of 0.876 (95% confidence interval, 0.803-0.925).

Conclusion

Patients with less severe hydronephrosis were less likely to have larger ureteral calculi.     

The effect of an observation unit on the rate of ED admission and discharge for pyelonephritis

Objectives

We sought to determine if the opening of an adult emergency department (ED) observation unit (OU) would impact the rate of hospital admission and ED discharges for pyelonephritis.

Methods

A retrospective cohort study was performed with all adult patients from October 2003 through December 2006 in the ED meeting inclusion criteria for pyelonephritis. Clinical, demographic, and laboratory data were recorded. Primary outcomes were rates of admission, ED discharge, and return ED visits before and after the opening of our OU. We compared admission, discharge, and readmission rates using the χ² test.

Results

Nine hundred thirty charts were reviewed with 633 included for analysis. Urine cultures were performed on 420 subjects with 71% being positive. The percentage of patients admitted to a hospital inpatient unit from the ED decreased from 36% to 26% (relative risk [RR], 0.73; P = .01) after opening the OU. The percentage of patients discharged home from the ED decreased from 65% to 51% (RR, 0.76; P < .001). Among OU patients, 29% were admitted to the hospital for further inpatient care. Emergency department recidivism was unchanged by opening the OU (RR, 0.86; P = .68).

Conclusions

The creation of an OU appears to influence admission decisions of ED physicians. We found that the creation of an OU significantly reduced hospital admissions for pyelonephritis but also significantly reduced ED discharges to home for pyelonephritis at our institution.     

The S/Z ratio: A simple and reliable clinical method of evaluating laryngeal function in patients after intubation

Objectives

1. To determine the consequences of prolonged intubation on laryngeal function.2. To evaluate simple clinical criteria or tests that could alert the clinician to potential laryngeal pathology requiring ear, nose, and throat/otolaryngology (ENT) referral.

Design

A prospective case series.

Setting

A surgical intensive care unit in a tertiary academic hospital in Cape Town, South Africa.

Participants

Thirty-two patients who had undergone a period of translaryngeal intubation for a period greater than 12 hours.

Main outcome measures

1. Patient subjective voice change rating.2. Clinician assessment of laryngeal function.3. S/Z ratio.4. Presence of laryngeal pathology on endoscopic assessment of the larynx.

Results

Upon initial evaluation within 6 hours of extubation, 26 (81%) of patients exhibited symptomatic laryngeal dysfunction. At this stage, 13 (40%) had S/Z ratios greater than 1.4. The degree of dysfunction as described by subjective scoring and the S/Z ratio was proportional to the duration of intubation. After 24 hours, 23 (72%) patients' voices had improved subjectively; and the S/Z ratio exceeded 1.4 in just 6 patients (19%). Of these 6 patients, 4 exhibited laryngeal pathology on flexible nasoendoscopy. These 4 patients were followed up over 1 year, and 1 patient was ultimately offered a vocal cord medialization procedure. The S/Z ratio is 100% sensitive and 93% specific, with an accuracy of 93.75%, in diagnosing laryngeal pathology requiring ENT referral.

Conclusions

1. A period of laryngeal intubation carries signification risk of laryngeal dysfunction. Most, but not all, dysfunction resolves within 24 hours.2. Residual laryngeal pathology can be reliably and simply screened for by the use of the S/Z ratio. We recommend that patients with an S/Z ratio greater than 1.4 more than 24 hours after extubation require ENT referral for laryngoscopy.     

The clinical quandary of counseling the moribund critical care patient—a registry analysis of postsurgical outcomes

Purpose

To provide outcomes data to intensivists and surgeons for counseling patients and family members when considering a surgical intervention in a moribund patient.

Materials and Methods

Retrospective analysis of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database in moribund patients undergoing general surgical procedures.

Results

Out of 633,262 patients available in the national registry, 2063 (0.3%) were of moribund status. Post-operative mortality was 52.8% for moribund patients. Those who died had higher rates of compromised respiratory, renal and cognitive dysfunction, were older, less independent prior to surgery and had generally longer surgeries. 83% of patients experienced a major complication including mortality and 17 % of patients experienced minor complications.

Conclusion

The moribund patient is not as grave as once thought and surgery on these patients may not be futile given the 47% survival rate at 30 days. Postoperative complication rates are high. The data presented provide a meaningful tool for the clinicians in counseling patients and families on the expectations when considering a surgical intervention for moribund patients.     

Indications and outcomes in children receiving renal replacement therapy in pediatric intensive care

Purpose

We aimed to describe patient characteristics, indications for renal replacement therapy (RRT), and outcomes in children requiring RRT. We hypothesized that fluid overload, not classic blood chemistry indications, would be the most frequent reason for RRT initiation.

Materials and Methods

A retrospective cohort study of all patients receiving RRT at a single-center quaternary pediatric intensive care unit between January 2004 and December 2008 was conducted.

Results

Ninety children received RRT. The median age was 7 months (interquartile range, 1-83). Forty-six percent of patients received peritoneal dialysis, and 54% received continuous renal replacement therapy. The median (interquartile range) PRISM-III score was 14 (8-19). Fifty-seven percent had congenital heart disease, and 32% were on extracorporeal life support. The most common clinical condition associated with acute kidney injury was hemodynamic instability (57%; 95% confidence interval [CI], 46-67), followed by multiorgan dysfunction syndrome (17%; 95% CI, 10-26). The most common indication for RRT initiation was fluid overload (77%; 95% CI, 66-86). Seventy-three percent (95% CI, 62-82) of patients survived to hospital discharge.

Conclusions

Hemodynamic instability and multiorgan dysfunction syndrome are the most common clinical conditions associated with acute kidney injury in our population. In the population studied, the mortality was lower than previously reported in children and much lower than in the adult population.     

Acute kidney injury risk in patients with ST-segment elevation myocardial infarction at presentation to the ED

Introduction

Acute kidney injury (AKI) is common in acute myocardial infarction (AMI) patients and has serious prognostic implications. The early identification of patients at risk of developing AKI at the emergency department (ED) can reduce its incidence.

Methods

Patients with ST-segment elevation myocardial infarction (STEMI) at the ED were included. Associated factors playing a role at ED presentation and during hospitalization were collected, and independent risk factors of developing AKI were assessed.

Results

Mean age among patients (n = 406, 69.7% male) was 62.5 ± 12.5 years. At ED admission, the mean glomerular filtration rate (GFR) was 70.5 ± 28.1 mL/min per 1.73 m², and 140 (34.5%) patients had a GFR < 60 mL/min per 1.73 m². Eighty-three patients (20.4%) developed AKI: 47 (11.6%) with stage 1, 26 (6.4%) with stage 2 and 10 (2.5%) with stage 3. Mortality was 11.8% and was higher in patients with AKI (34.9% vs 5.9%, P < .0001). Univariate analysis disclosed age, reduced GFR at presentation, severe Killip class, heart rate and longer door-to-needle time as risk factors to develop AKI. Moreover, these patients received less β-blocker and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in the ED. Multivariate analysis revealed that age, Killip class, heart rate, door-to-needle time, and β-blocker non-use were independent factors associated with AKI. These factors provided the ED physician with good accuracy in identifying patients at high risk of developing AKI.

Conclusion

Factors associated with AKI in STEMI patients allowed physicians to identify patients at high risk in the ED. Moreover, reduced door-to-needle time and β-blocker use were associated with renal protection in AMI patients.     

Patients with cardiac arrest are ventilated two times faster than guidelines recommend: An observational prehospital study using tracheal pressure measurement

Aim

To measure ventilation rate using tracheal airway pressures in prehospitally intubated patients with and without cardiac arrest.

Methods

Prospective observational study. In 98 patients (57 with and 41 without cardiac arrest) an air-filled catheter was inserted into the endotracheal tube and connected to a custom-made portable device allowing tracheal airway pressure recording and subsequent calculation of ventilation rate.

Results

In manually ventilated patients with cardiac arrest 39/43 (90%) had median ventilation rates higher than 10/min (overall median 20, min 4, max 74). During mechanical ventilation, 35/38 (92%) had ventilation rates higher than 10/min. The ventilation rate in patients with cardiac arrest was higher than in patients without cardiac arrest, both for manual and mechanical ventilation. Subanalysis comparing episodes with and without compression in cardiac arrest patients showed no clinically significant difference in ventilation rate after compressions were terminated.

Conclusion

Cardiac arrest patients were ventilated two times faster than recommended by the guidelines. Tracheal airway pressure measurement is feasible during resuscitation and may be developed further to provide real-time feedback on airway pressure and ventilation rate during resuscitation.     

Performance of a body surface mapping system using emergency physician real-time interpretation

Objective

We compared the performance characteristics of the 12-lead electrocardiography (ECG) with body surface mapping (BSM) in patients presenting for evaluation of symptoms suggestive of acute coronary syndromes.

Methods

The diagnostic test characteristics (sensitivity, specificity, likelihood ratios, and predictive values) for 12-lead ECG and BSM were computed using 3 different criterion standards.

Results

Of the 150 patients enrolled, 19 were positive for acute coronary syndromes using the criterion standard of cardiac troponin T >0.1 ng/mL, percutaneous coronary intervention, more than 70% stenosis, abnormal noninvasive testing, and coronary artery bypass graft. Changes not known to be old on ECG and BSM had sensitivities of 10.5 (95% confidence interval [CI₉₅], 1.8-34.5) and 15.8 (CI₉₅, 4.2-40.5), and specificities of 90.1 (CI₉₅, 83.3-94.4) and 86.3 (CI₉₅, 78.9-91.4), respectively.

Conclusion

In this emergency department population, both the BSM and the 12-lead ECG exhibited similar test characteristics.     

Clinical predictors for testicular torsion as seen in the pediatric ED

Objective

The aim of the study was to identify clinical findings associated with increased likelihood of testicular torsion (TT) in children.

Design

This study used a retrospective case series of children with acute scrotum presenting to a pediatric emergency department (ED).

Results

Five hundred twenty-three ED visits were analyzed. Mean patient age was 10 years 9 months. Seventeen (3.25%) patients had TT. Pain duration of less than 24 hours (odds ratio [OR], 6.66; 95% confidence interval [CI], 1.54-33.33), nausea and/or vomiting (OR, 8.87; 95% CI, 2.6-30.1), abnormal cremasteric reflex (OR, 27.77; 95% CI, 7.5-100), abdominal pain (OR, 3.19; 95% CI, 1.15-8.89), and high position of the testis (OR, 58.8; 95% CI, 19.2-166.6) were associated with increased likelihood of torsion.

Conclusions

Testicular torsion is uncommon among pediatric patients presenting to the ED with acute scrotum. Pain duration of less than 24 hours, nausea or vomiting, high position of the testicle, and abnormal cremasteric reflex are associated with higher likelihood of torsion.     

Acute kidney injury after cardiac surgery according to Risk/Injury/Failure/Loss/End-stage,Acute Kidney Injury Network,and Kidney Disease: Improving Global Outcomes classifications

Purpose

The epidemiology of acute kidney injury (AKI) after cardiac surgery depends on the definition used. Our aims were to evaluate the Risk/Injury/Failure/Loss/End-stage (RIFLE) criteria, the AKI Network (AKIN) classification, and the Kidney Disease: Improving Global Outcomes (KDIGO) classification for AKI post–cardiac surgery and to compare the outcome of patients on renal replacement therapy (RRT) with historical data.

Methods

Retrospective analysis of 1881 adults who had cardiac surgery between May 2006 and April 2008 and determination of the maximum AKI stage according to the AKIN, RIFLE, and KDIGO classifications.

Results

The incidence of AKI using the AKIN and RIFLE criteria was 25.9% and 24.9%, respectively, but individual patients were classified differently. The area under the receiver operating characteristic curve for hospital mortality was significantly higher using the AKIN compared with the RIFLE criteria (0.86 vs 0.78, P = .0009). Incidence and outcome of AKI according to the AKIN and KDIGO classification were identical. The percentage of patients who received RRT was 6.2% compared with 2.7% in 1989 to 1990. The associated hospital mortality fell from 82.9% in 1989 to 1990 to 15.6% in 2006 to 2008.

Conclusions

The AKIN classification correlated better with mortality than did the RIFLE criteria. Mortality of patients needing RRT after cardiac surgery has improved significantly during the last 20 years.     

Estimating glomerular filtration rate (GFR) in diabetes: The performance of MDRD and CKD-EPI equations in patients with various degrees of albuminuria

Objectives

The aim of this study was to compare the performance of Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Modification of Diet in Renal Disease Study (MDRD) equations in estimating GFR in a large cohort of diabetic patients with various degrees of albuminuria.

Design and methods

In a group of 842 diabetic patients GFR was estimated from standardized creatinine, with MDRD-Study and CKD-EPI equations, and their performance evaluated regarding clinical stages of albuminuria and chronic kidney disease (CKD).

Results

Patients with normoalbuminuria had higher eGFR when calculated by CKD-EPI, than MDRD-Study equation [median (IQR): 103 (91–115) vs 97 (85–113) mL/min/1.73 m², P = 0.006, n = 364], which significantly influenced the prevalence of stage 1 CKD [eGFR > 90 mL/min/1.73 m²: 76.7% (CKD-EPI) vs. 65.1% (MDRD-Study), P = 0.005]. There were no differences between the eGFR values derived by two equations in patients with micro- and macroalbuminuria, and more advanced staging of CKD.

Conclusion

CKD-EPI equation might be a superior surrogate marker of GFR in patients with normoalbuminuria and hyperfiltration and could be used as a screening tool for early renal impairment in diabetes. It's validity as a marker of progression of diabetic nephropathy merits further investigation.     

Renal dysfunction as a risk factor for painless myocardial infarction: results from Korea Acute Myocardial Infarction Registry

Aim

Renal dysfunction has been associated with many types of neuropathy and the incidence of myocardial infarction (MI) presenting without chest pain can be expected to be higher in patients with renal dysfunction. We evaluated clinical outcomes of painless MI patients and relationship between renal dysfunction and painless MI.

Methods and results

Study population consisted of 9,735 patients (63?±?13?years, men 70.7?%), whose discharge diagnosis by cardiac enzyme and electrocardiogram was MI. The study subjects were divided into two groups according to presence of chest pain (painful MI group, n?=?8,249; painless MI group, n?=?1486). Rates of in-hospital death, 1-month and 12-month composite MACE, cardiac death, and non-cardiac death were significantly higher in painless MI patients. In a multivariate logistic analysis, compared with glomerular filtration rate (GFR)?>?90?mL/min/1.73?m², odds ratio of painless MI was increased proportionally in patients with GFR of 30–59, 15–29 and <15?mL/min/1.73?m² (odds ratio [OR] 1.25, 95?% confidence interval [CI] 1.05–1.49; OR 1.88, CI 1.39–2.53; OR 2.32, CI 1.65–3.26) In addition, the concomitant presence of renal dysfunction and diabetes mellitus significantly affected the prevalence of painless MI.

Conclusion

Poorer outcomes of painless MI patients and the increased probability of painless MI proportional to declining GFR indicate that the possibility of painless MI should be considered in patients with renal dysfunction, particularly concomitant with diabetes mellitus.     

Predictive accuracy of ST depression during rapid atrial fibrillation on the presence of obstructive coronary artery disease

Background

Rapid atrial fibrillation (AF) is commonly associated with ST-segment depressions. ST-segment depression during a chest pain episode or exercise stress testing in sinus rhythm is predictive of obstructive coronary artery disease (CAD), but it is unclear if the presence or magnitude of ST-segment depression during rapid AF has similar predictive accuracy.

Methods

One hundred twenty-seven patients with rapid AF (heart rate ≥120 beats per minute) who had cardiac catheterization performed during the same hospital admission were retrospectively reviewed. Variables to compute thrombolysis in myocardial infarction (TIMI) risk score, demographic profiles, ST-segment deviation, cardiac catheterization results, and cardiac interventions were collected.

Results

Thirty-five patients had ST-segment depression of 1 mm or more, and 92 had no or less than 1 mm ST depression. Thirty-one patients were found to have obstructive CAD. In the group with ST-segment depression, 11 (31%) patients had obstructive CAD and 24 (69%) did not. In the group with less than 1 mm ST-segment depression, 20 (22%) had obstructive CAD and 72 (78%) did not (P = .25). Sensitivity, specificity, and positive and negative predictive values for presence of obstructive CAD were 35%, 75%, 31%, and 78%, respectively. The presence of ST-segment depression of 1 mm or more was not associated with presence of obstructive CAD before or after adjustment of TIMI variables. The relationship between increasing grades of ST-segment depression and obstructive CAD showed a trend toward significance (P = .09), which did not persist after adjusting for TIMI risk variables (P = .36).

Conclusion

ST-segment depression during rapid AF is not predictive for the presence of obstructive CAD.     

Mortality and complications in elderly patients undergoing cardiac surgery

Purpose

The purpose of the study was to analyze postoperative complications, mortality, and related factors of elderly patients undergoing cardiac surgery.

Methods

An observational, retrospective, and multicenter study of cardiac surgery patients, obtained from the ARIAM registry, was performed between 2008 and 2011. Clinical-surgical data, postoperative complications, and mortality were analyzed in a group of patients older than 75 years and in a younger group.

Results

A total of 4548 patients were analyzed, with 882 (19.4%) patients at least 75 years old. Elderly patients had worse functional status (New York heart Association class) and comorbidities. The complication rate was higher in the elderly group (40.4% and 33.5%, respectively; P = .0001). Mortality in the elderly was 1.1%, 12%, and 15.1% (during surgery, intensive care unit [ICU], and 30-day mortality, respectively). Thirty-day mortality in elderly patients was higher when adjusted for EuroSCORE (European System for Cardiac Operative Risk Evaluation) and cardiopulmonary bypass time.The interaction between multiorgan dysfunction syndrome (MODS) and age more than 75 years was assessed by logistic regression, obtaining an odds ratio of 9.27 (5.88-14.60) for younger patients and 29.44 (12.22-70.94) for elderly patients who died during the ICU stay.

Conclusions

Age more than 75 years is an independent risk factor for ICU mortality when adjusted for EuroSCORE and cardiopulmonary bypass time. Elderly patients also have a higher rate of complications during ICU stay. Elderly patients develop MODS more frequently and present a higher mortality rate than younger patients with MODS.