This document discusses the cardiology perspective on out-of-hospital cardiac arrest (OOHCA). It notes that coronary artery disease is a common underlying cause of OOHCA and that observational studies have found high rates of obstructive coronary anatomy in OOHCA patients. While randomized controlled trials are lacking, registry data suggests early invasive coronary angiography and revascularization may improve outcomes for select OOHCA patients, especially those presenting in ventricular fibrillation or tachycardia. However, patient selection is important as those undergoing early intervention procedures tend to be lower risk. The optimal strategy also remains unclear as not all coronary stenoses may need immediate treatment. Potential harms of early angiography include bleeding complications.
This presentation covers various aspects of OHCA scenarios, including incidence, outcome, challenges, solutions, hen to initiate CPR, protocols, Termination, ECPR, and other issues are covering in details. Explore regional experiences in training and OHCA results as well.
Brugada Syndrome and LQTS - the evidenceJunhao Koh
Brugada Syndrome and Long QT Syndrome are cardiac conditions that can cause abnormal heart rhythms and sudden cardiac death. For Brugada Syndrome, the key aspects of diagnosis, risk stratification, and management discussed include identifying type 1 ECG patterns, assessing risk based on exercise stress tests and signal-averaged ECGs, and treating high-risk patients with medications like quinidine or catheter ablation. For Long QT Syndrome, diagnosis involves measuring the corrected QT interval on ECG, risk stratification considers specific genetic mutations and history of syncope, and management relies on beta blockers and ICDs for high-risk patients. Both conditions require careful medical management to reduce risks of life-threatening arrhythmias.
This document discusses best practices for caring for lung transplant recipients in the ICU. It covers indications for ECMO pre-transplant as a bridge to transplant, features and treatment of primary graft dysfunction post-transplant, and appropriate ventilation and hemodynamic support. It also provides guidance for community hospitals on evaluating and initially managing lung transplant patients who present with complications.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
Surgical management of aortic arch pathology often requires complex techniques to protect vital organs like the brain during replacement or repair of the aortic arch. Conventional techniques used hypothermic circulatory arrest and surface cooling but had limitations. Newer techniques like antegrade and retrograde selective cerebral perfusion allow prolonged safe periods of cerebral protection with improved cooling and independent control of cerebral and systemic circulation, though they are more technically challenging. The optimal approach considers individual patient and anatomical factors to maximize benefits and reduce risks.
Implantable cardiac electronic device infections can occur at rates between 0.5-2.2% depending on factors like the type of procedure and patient comorbidities. Common causative organisms include Staphylococcus aureus and Staphylococcus epidermidis, with about 1/3 of infections being methicillin-resistant. Diagnosis relies on clinical signs combined with microbiological testing of blood, device surfaces, and pocket tissues. Proper sampling and rapid processing is important for identifying the pathogen and guiding antibiotic treatment.
Hybrid tevar for the treatment of aortic dissectionuvcd
- Hybrid TEVAR involves using open surgery and endovascular stent grafting to treat aortic dissection.
- It can be used for acute type A dissection to allow total arch repair followed by TEVAR for the descending thoracic aorta. It is also indicated for chronic type B dissection when there is no suitable proximal landing zone by creating one through open surgery.
- The author presents results from their hospital demonstrating the safety and effectiveness of hybrid TEVAR for both acute type A and chronic type B dissection, with favorable outcomes including high rates of false lumen thrombosis and regression.
This document discusses PCI (percutaneous coronary intervention) versus CABG (coronary artery bypass grafting) for treating stable coronary artery disease. It provides historical context on the evolution of both procedures and summarizes key randomized controlled trials comparing outcomes of PCI versus CABG. The trials show that CABG provided better long-term outcomes than balloon angioplasty or bare metal stents in multivessel disease. Later trials with drug-eluting stents still found CABG superior for left main or multivessel disease, though the differences were smaller. CABG remains the standard of care for more complex anatomies while PCI is preferred for simpler cases.
This presentation covers various aspects of OHCA scenarios, including incidence, outcome, challenges, solutions, hen to initiate CPR, protocols, Termination, ECPR, and other issues are covering in details. Explore regional experiences in training and OHCA results as well.
Brugada Syndrome and LQTS - the evidenceJunhao Koh
Brugada Syndrome and Long QT Syndrome are cardiac conditions that can cause abnormal heart rhythms and sudden cardiac death. For Brugada Syndrome, the key aspects of diagnosis, risk stratification, and management discussed include identifying type 1 ECG patterns, assessing risk based on exercise stress tests and signal-averaged ECGs, and treating high-risk patients with medications like quinidine or catheter ablation. For Long QT Syndrome, diagnosis involves measuring the corrected QT interval on ECG, risk stratification considers specific genetic mutations and history of syncope, and management relies on beta blockers and ICDs for high-risk patients. Both conditions require careful medical management to reduce risks of life-threatening arrhythmias.
This document discusses best practices for caring for lung transplant recipients in the ICU. It covers indications for ECMO pre-transplant as a bridge to transplant, features and treatment of primary graft dysfunction post-transplant, and appropriate ventilation and hemodynamic support. It also provides guidance for community hospitals on evaluating and initially managing lung transplant patients who present with complications.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
Surgical management of aortic arch pathology often requires complex techniques to protect vital organs like the brain during replacement or repair of the aortic arch. Conventional techniques used hypothermic circulatory arrest and surface cooling but had limitations. Newer techniques like antegrade and retrograde selective cerebral perfusion allow prolonged safe periods of cerebral protection with improved cooling and independent control of cerebral and systemic circulation, though they are more technically challenging. The optimal approach considers individual patient and anatomical factors to maximize benefits and reduce risks.
Implantable cardiac electronic device infections can occur at rates between 0.5-2.2% depending on factors like the type of procedure and patient comorbidities. Common causative organisms include Staphylococcus aureus and Staphylococcus epidermidis, with about 1/3 of infections being methicillin-resistant. Diagnosis relies on clinical signs combined with microbiological testing of blood, device surfaces, and pocket tissues. Proper sampling and rapid processing is important for identifying the pathogen and guiding antibiotic treatment.
Hybrid tevar for the treatment of aortic dissectionuvcd
- Hybrid TEVAR involves using open surgery and endovascular stent grafting to treat aortic dissection.
- It can be used for acute type A dissection to allow total arch repair followed by TEVAR for the descending thoracic aorta. It is also indicated for chronic type B dissection when there is no suitable proximal landing zone by creating one through open surgery.
- The author presents results from their hospital demonstrating the safety and effectiveness of hybrid TEVAR for both acute type A and chronic type B dissection, with favorable outcomes including high rates of false lumen thrombosis and regression.
This document discusses PCI (percutaneous coronary intervention) versus CABG (coronary artery bypass grafting) for treating stable coronary artery disease. It provides historical context on the evolution of both procedures and summarizes key randomized controlled trials comparing outcomes of PCI versus CABG. The trials show that CABG provided better long-term outcomes than balloon angioplasty or bare metal stents in multivessel disease. Later trials with drug-eluting stents still found CABG superior for left main or multivessel disease, though the differences were smaller. CABG remains the standard of care for more complex anatomies while PCI is preferred for simpler cases.
Aortic Valve Sparring Root Replacement David vs yacoubDicky A Wartono
The document discusses different techniques for aortic valve-sparing operations, including the remodeling technique developed by Yacoub and the reimplantation technique developed by David. It describes the technical steps for each procedure and compares their early mortality rates and long-term outcomes. While both techniques can successfully preserve native valve function, the reimplantation technique may be preferable to remodeling for certain patient anatomies or pathologies like bicuspid valves, Marfan syndrome, or acute aortic dissection. Intraoperative imaging is important for assessing valve competence after repair.
LVNC is a rare genetic cardiomyopathy characterized by a spongy appearance of the myocardium due to incomplete compaction of the embryonic myocardium. It can present with heart failure, arrhythmias, or thromboembolism. Echocardiography and cardiac MRI are used to diagnose LVNC based on identifying a two-layered myocardium. Management involves treating heart failure and preventing thromboembolism with anticoagulation in high-risk patients. While the cause of LVNC is thought to be due to an arrest in normal myocardial compaction during embryonic development, the pathophysiology is not fully understood.
Non cardaic surgery preoperative cardiac evaluation aha esc guideline 2015rajasekar nagarajan
The document provides guidelines for preoperative evaluation of patients with cardiac disease undergoing noncardiac surgery. It discusses evaluating factors like the urgency of surgery, cardiac stability, and surgical risk level. Functional capacity is an important predictor of perioperative risk. Testing like ECG, echocardiogram, stress testing and angiography are recommended depending on the patient's risk level and functional capacity. Coronary revascularization before surgery is only recommended if indicated by existing guidelines. Overall preoperative evaluation and management depends on balancing cardiac and surgical risk on an individual basis.
This document provides information on hypertrophic cardiomyopathy (HCM), including its definition, history, etiology, pathophysiology, diagnosis, and clinical presentation. HCM is a genetic heart condition characterized by thickened heart muscle not caused by other conditions like high blood pressure. It affects around 1 in 500 people and can cause chest pain, dizziness, and heart failure. The pathophysiology involves left ventricular outflow tract obstruction, diastolic dysfunction, myocardial ischemia, and mitral regurgitation. Diagnosis involves imaging of the thickened heart muscle. Most patients are asymptomatic but may develop limiting symptoms like shortness of breath or chest pain in their 40s-60s as obstruction develops.
Guidelines and beyond new drug therapy for heart failure with reduced ejectio...ahvc0858
This document provides information on new guidelines and therapies for heart failure patients. It begins by outlining the challenges of managing heart failure patients and their high mortality rates. It then discusses the history of heart failure treatments from ACE inhibitors in the 1990s to newer drugs like ARNi's. The document defines the different types of heart failure - HFrEF, HFmrEF, and HFpEF - and their diagnostic criteria. It explains how neprilysin inhibition enhances natriuretic peptides while simultaneously suppressing the RAAS. Finally, it summarizes that the new drug LCZ696 combines neprilysin inhibition with an ARB to reduce mortality and hospitalization in heart failure patients beyond existing neurohormonal therapies
Guidelines in the management of carotid stenosisuvcd
This document provides an overview of guidelines for the management of carotid stenosis. It discusses:
1) Stroke is a major cause of death, with many caused by carotid artery disease. The risk of stroke is directly related to the degree of stenosis.
2) Natural history studies show that the risk of stroke is highest in the first year after symptoms and then declines over time. The risk is higher for more severe stenosis.
3) Early trials demonstrated the benefits of carotid endarterectomy (CEA) in reducing stroke risks compared to medical management alone for symptomatic and some asymptomatic patients.
4) Later trials evaluated carotid angioplasty and stenting (CAS) as an alternative to CEA but
Coronary artery dissection and perforationFuad Farooq
Coronary artery dissection and perforation are serious potential complications of percutaneous coronary intervention (PCI) that can be life-threatening. Up to 30% of conventional balloon angioplasties result in angiographically significant coronary artery dissection. Perforation occurs in 0.3-0.6% of all PCI cases. The development of devices to remove or ablate tissue has increased the risk of these complications. Types C through F dissections according to the NHLBI classification portend significant morbidity and mortality if untreated, as they can lead to total coronary occlusion without blood flow. Acute vessel closure was the most feared complication before stents but now occurs in less than 1% of elective PCI due to stenting
The document discusses various clinical trials related to cardiovascular diseases. It summarizes the ACCORD BP study which found that targeting a SBP of <120 mm Hg compared to <140 mm Hg in patients with type 2 diabetes did not reduce cardiovascular events. It also summarizes the HOPE trial which found that ramipril reduced cardiovascular deaths, myocardial infarction, and stroke in high-risk patients without low ejection fraction or heart failure. Finally, it summarizes the EUROPA trial which found that perindopril reduced the primary endpoint of cardiovascular mortality, non-fatal MI, and cardiac arrest in patients with stable coronary artery disease.
The document reports on a study from the ISCHEMIA trial investigating the impact of complete versus incomplete revascularization on clinical outcomes in patients with stable ischemic heart disease treated with an invasive versus conservative strategy. It finds that among patients treated with an invasive strategy, complete anatomic or functional revascularization was associated with improved outcomes compared to incomplete revascularization. However, after adjustment for covariates, the differences in outcomes between complete and incomplete revascularization were no longer statistically significant.
This document discusses the Bentall procedure for treating type A aortic dissection and revisits its use. It provides an overview of the history and anatomy relevant to the procedure. It then summarizes some studies comparing outcomes of the Bentall procedure versus the Ross procedure or valve-sparing surgery for acute type A dissection. The document concludes that the Bentall procedure remains a safe and less painful option for aortic root dissection with reasonable outcomes when the coronary buttons are properly placed.
ECMO CPR
ECMO in Cardiac arrest has increased exponentially in the past 10 years, on the back of, up until very recently, non-randomised, predominantly retrospective studies.
What is the efficacy?
Appropriate patient selection?
Cost effectiveness and model of delivery of ECPR?
Finally is ECMO really the intervention or just optimising the chain of survival?
Spinal cord protection in aortic surgeriesthanigai arasu
Spinal cord protection is important during aortic surgeries to prevent neurological deficits. The risk is highest with open thoracoabdominal aortic aneurysm (TAAA) repair. Techniques to protect the spinal cord include minimizing ischemia time, increasing cord tolerance through hypothermia, augmenting perfusion, and monitoring for ischemia. Early detection of ischemia allows interventions like reattachment of segmental arteries or modifying perfusion to salvage the cord. While endovascular repair reduces risk compared to open surgery, open repair requires strategies like distal aortic perfusion, cerebrospinal fluid drainage and evoked potential monitoring to optimize spinal cord protection.
This document provides guidelines for perioperative cardiovascular evaluation and management for patients undergoing non-cardiac surgery. It discusses preoperative clinical evaluation, testing, management of specific cardiovascular conditions, supplemental evaluation like ECG and stress testing, considerations for patients with prior coronary revascularization, perioperative medical therapy, intraoperative management, postoperative surveillance and long-term management. The document provides a stepwise approach and recommendations for evaluation and treatment of cardiovascular issues in the perioperative period.
Case presentation ,double chambered right ventricleAliaa Shaban
This document presents a case study of a 19-year-old male with a history of surgical closure of a ventricular septal defect and resection of a subaortic membrane as a child. He later developed shortness of breath. Transthoracic echocardiography revealed a double-chambered right ventricle, which is a rare congenital anomaly where an anomalous muscle band divides the right ventricle into two chambers. Though considered acquired, it is commonly associated with other congenital anomalies like ventricular septal defects. Surgical intervention is indicated for symptomatic patients or those with a peak gradient over 40 mm Hg.
The document provides the top 10 take-home messages from the 2021 ACC/AHA/AATS/STS/SCAI Guideline for Coronary Artery Revascularization. It emphasizes using a multidisciplinary Heart Team approach for unclear treatment cases, considering surgical revascularization for left main disease and triple-vessel disease, and using radial artery access for percutaneous interventions to reduce complications. It also recommends strategies to improve equity in treatment decisions and shared decision-making.
This document discusses leadless pacemakers and biological pacemakers. It provides a history of pacemakers and their complications. Leadless pacemakers were developed to avoid complications from transvenous leads. They are self-contained devices implanted inside the heart without leads. Biological pacemakers use gene or cell therapy to produce electrical stimuli mimicking the body's natural pacemaker cells, avoiding regular replacement needs. The document examines various leadless pacemaker designs and a biological pacing strategy using stem cells.
Which mechanical circulatory support should we use as first line optiondrucsamal
1) Temporary mechanical circulatory support options like intra-aortic balloon pumps, Impella pumps, TandemHeart pumps, and extracorporeal membrane oxygenation (ECMO) can be used as first-line support for acute cardiogenic shock.
2) These temporary options are placed percutaneously in the catheterization lab and can provide partial to full cardiac output support.
3) Larger ventricular assist devices require open heart surgery and are better suited for longer term chronic support if the patient does not recover with temporary support. The optimal support strategy depends on the individual patient's clinical status and prognosis.
ARITMIE VENTRICOLARI NEI CONGENITI ADULTI: INDICAZIONI E TIMING DELL’ABLAZIONEpasqualevergara1
This document discusses risk stratification and management of ventricular arrhythmias in adults with congenital heart disease, particularly those with tetralogy of Fallot (ToF). It finds that ventricular tachycardia (VT) ablation is effective for treating VTs in ToF patients, with most VTs being fast and monomorphic. Risk factors for sudden cardiac death in ToF include prolonged QRS duration, ventricular dysfunction, nonsustained VT on Holter monitoring, and syncope. Cardiac MRI can identify predictors of death and sustained VT like right ventricular hypertrophy and fibrosis. Electrophysiological study can assess risk and guide decisions about implantable cardioverter defibrillator placement.
This presentation discusses how to evaluate shock using echocardiography. It defines shock and describes the main types: hypovolemic, cardiogenic, obstructive, and distributive. Guidelines recommend using echo to evaluate shock. The presentation reviews how to assess left ventricular systolic function, volume status, valvular pathology, and diastolic function. It provides examples of using echo to diagnose specific causes of shock like sepsis, myocardial infarction, pulmonary embolism, and tamponade. The key messages are that echo is very useful for diagnosing and managing shock, and training in point-of-care ultrasound is important.
Aortic Valve Sparring Root Replacement David vs yacoubDicky A Wartono
The document discusses different techniques for aortic valve-sparing operations, including the remodeling technique developed by Yacoub and the reimplantation technique developed by David. It describes the technical steps for each procedure and compares their early mortality rates and long-term outcomes. While both techniques can successfully preserve native valve function, the reimplantation technique may be preferable to remodeling for certain patient anatomies or pathologies like bicuspid valves, Marfan syndrome, or acute aortic dissection. Intraoperative imaging is important for assessing valve competence after repair.
LVNC is a rare genetic cardiomyopathy characterized by a spongy appearance of the myocardium due to incomplete compaction of the embryonic myocardium. It can present with heart failure, arrhythmias, or thromboembolism. Echocardiography and cardiac MRI are used to diagnose LVNC based on identifying a two-layered myocardium. Management involves treating heart failure and preventing thromboembolism with anticoagulation in high-risk patients. While the cause of LVNC is thought to be due to an arrest in normal myocardial compaction during embryonic development, the pathophysiology is not fully understood.
Non cardaic surgery preoperative cardiac evaluation aha esc guideline 2015rajasekar nagarajan
The document provides guidelines for preoperative evaluation of patients with cardiac disease undergoing noncardiac surgery. It discusses evaluating factors like the urgency of surgery, cardiac stability, and surgical risk level. Functional capacity is an important predictor of perioperative risk. Testing like ECG, echocardiogram, stress testing and angiography are recommended depending on the patient's risk level and functional capacity. Coronary revascularization before surgery is only recommended if indicated by existing guidelines. Overall preoperative evaluation and management depends on balancing cardiac and surgical risk on an individual basis.
This document provides information on hypertrophic cardiomyopathy (HCM), including its definition, history, etiology, pathophysiology, diagnosis, and clinical presentation. HCM is a genetic heart condition characterized by thickened heart muscle not caused by other conditions like high blood pressure. It affects around 1 in 500 people and can cause chest pain, dizziness, and heart failure. The pathophysiology involves left ventricular outflow tract obstruction, diastolic dysfunction, myocardial ischemia, and mitral regurgitation. Diagnosis involves imaging of the thickened heart muscle. Most patients are asymptomatic but may develop limiting symptoms like shortness of breath or chest pain in their 40s-60s as obstruction develops.
Guidelines and beyond new drug therapy for heart failure with reduced ejectio...ahvc0858
This document provides information on new guidelines and therapies for heart failure patients. It begins by outlining the challenges of managing heart failure patients and their high mortality rates. It then discusses the history of heart failure treatments from ACE inhibitors in the 1990s to newer drugs like ARNi's. The document defines the different types of heart failure - HFrEF, HFmrEF, and HFpEF - and their diagnostic criteria. It explains how neprilysin inhibition enhances natriuretic peptides while simultaneously suppressing the RAAS. Finally, it summarizes that the new drug LCZ696 combines neprilysin inhibition with an ARB to reduce mortality and hospitalization in heart failure patients beyond existing neurohormonal therapies
Guidelines in the management of carotid stenosisuvcd
This document provides an overview of guidelines for the management of carotid stenosis. It discusses:
1) Stroke is a major cause of death, with many caused by carotid artery disease. The risk of stroke is directly related to the degree of stenosis.
2) Natural history studies show that the risk of stroke is highest in the first year after symptoms and then declines over time. The risk is higher for more severe stenosis.
3) Early trials demonstrated the benefits of carotid endarterectomy (CEA) in reducing stroke risks compared to medical management alone for symptomatic and some asymptomatic patients.
4) Later trials evaluated carotid angioplasty and stenting (CAS) as an alternative to CEA but
Coronary artery dissection and perforationFuad Farooq
Coronary artery dissection and perforation are serious potential complications of percutaneous coronary intervention (PCI) that can be life-threatening. Up to 30% of conventional balloon angioplasties result in angiographically significant coronary artery dissection. Perforation occurs in 0.3-0.6% of all PCI cases. The development of devices to remove or ablate tissue has increased the risk of these complications. Types C through F dissections according to the NHLBI classification portend significant morbidity and mortality if untreated, as they can lead to total coronary occlusion without blood flow. Acute vessel closure was the most feared complication before stents but now occurs in less than 1% of elective PCI due to stenting
The document discusses various clinical trials related to cardiovascular diseases. It summarizes the ACCORD BP study which found that targeting a SBP of <120 mm Hg compared to <140 mm Hg in patients with type 2 diabetes did not reduce cardiovascular events. It also summarizes the HOPE trial which found that ramipril reduced cardiovascular deaths, myocardial infarction, and stroke in high-risk patients without low ejection fraction or heart failure. Finally, it summarizes the EUROPA trial which found that perindopril reduced the primary endpoint of cardiovascular mortality, non-fatal MI, and cardiac arrest in patients with stable coronary artery disease.
The document reports on a study from the ISCHEMIA trial investigating the impact of complete versus incomplete revascularization on clinical outcomes in patients with stable ischemic heart disease treated with an invasive versus conservative strategy. It finds that among patients treated with an invasive strategy, complete anatomic or functional revascularization was associated with improved outcomes compared to incomplete revascularization. However, after adjustment for covariates, the differences in outcomes between complete and incomplete revascularization were no longer statistically significant.
This document discusses the Bentall procedure for treating type A aortic dissection and revisits its use. It provides an overview of the history and anatomy relevant to the procedure. It then summarizes some studies comparing outcomes of the Bentall procedure versus the Ross procedure or valve-sparing surgery for acute type A dissection. The document concludes that the Bentall procedure remains a safe and less painful option for aortic root dissection with reasonable outcomes when the coronary buttons are properly placed.
ECMO CPR
ECMO in Cardiac arrest has increased exponentially in the past 10 years, on the back of, up until very recently, non-randomised, predominantly retrospective studies.
What is the efficacy?
Appropriate patient selection?
Cost effectiveness and model of delivery of ECPR?
Finally is ECMO really the intervention or just optimising the chain of survival?
Spinal cord protection in aortic surgeriesthanigai arasu
Spinal cord protection is important during aortic surgeries to prevent neurological deficits. The risk is highest with open thoracoabdominal aortic aneurysm (TAAA) repair. Techniques to protect the spinal cord include minimizing ischemia time, increasing cord tolerance through hypothermia, augmenting perfusion, and monitoring for ischemia. Early detection of ischemia allows interventions like reattachment of segmental arteries or modifying perfusion to salvage the cord. While endovascular repair reduces risk compared to open surgery, open repair requires strategies like distal aortic perfusion, cerebrospinal fluid drainage and evoked potential monitoring to optimize spinal cord protection.
This document provides guidelines for perioperative cardiovascular evaluation and management for patients undergoing non-cardiac surgery. It discusses preoperative clinical evaluation, testing, management of specific cardiovascular conditions, supplemental evaluation like ECG and stress testing, considerations for patients with prior coronary revascularization, perioperative medical therapy, intraoperative management, postoperative surveillance and long-term management. The document provides a stepwise approach and recommendations for evaluation and treatment of cardiovascular issues in the perioperative period.
Case presentation ,double chambered right ventricleAliaa Shaban
This document presents a case study of a 19-year-old male with a history of surgical closure of a ventricular septal defect and resection of a subaortic membrane as a child. He later developed shortness of breath. Transthoracic echocardiography revealed a double-chambered right ventricle, which is a rare congenital anomaly where an anomalous muscle band divides the right ventricle into two chambers. Though considered acquired, it is commonly associated with other congenital anomalies like ventricular septal defects. Surgical intervention is indicated for symptomatic patients or those with a peak gradient over 40 mm Hg.
The document provides the top 10 take-home messages from the 2021 ACC/AHA/AATS/STS/SCAI Guideline for Coronary Artery Revascularization. It emphasizes using a multidisciplinary Heart Team approach for unclear treatment cases, considering surgical revascularization for left main disease and triple-vessel disease, and using radial artery access for percutaneous interventions to reduce complications. It also recommends strategies to improve equity in treatment decisions and shared decision-making.
This document discusses leadless pacemakers and biological pacemakers. It provides a history of pacemakers and their complications. Leadless pacemakers were developed to avoid complications from transvenous leads. They are self-contained devices implanted inside the heart without leads. Biological pacemakers use gene or cell therapy to produce electrical stimuli mimicking the body's natural pacemaker cells, avoiding regular replacement needs. The document examines various leadless pacemaker designs and a biological pacing strategy using stem cells.
Which mechanical circulatory support should we use as first line optiondrucsamal
1) Temporary mechanical circulatory support options like intra-aortic balloon pumps, Impella pumps, TandemHeart pumps, and extracorporeal membrane oxygenation (ECMO) can be used as first-line support for acute cardiogenic shock.
2) These temporary options are placed percutaneously in the catheterization lab and can provide partial to full cardiac output support.
3) Larger ventricular assist devices require open heart surgery and are better suited for longer term chronic support if the patient does not recover with temporary support. The optimal support strategy depends on the individual patient's clinical status and prognosis.
ARITMIE VENTRICOLARI NEI CONGENITI ADULTI: INDICAZIONI E TIMING DELL’ABLAZIONEpasqualevergara1
This document discusses risk stratification and management of ventricular arrhythmias in adults with congenital heart disease, particularly those with tetralogy of Fallot (ToF). It finds that ventricular tachycardia (VT) ablation is effective for treating VTs in ToF patients, with most VTs being fast and monomorphic. Risk factors for sudden cardiac death in ToF include prolonged QRS duration, ventricular dysfunction, nonsustained VT on Holter monitoring, and syncope. Cardiac MRI can identify predictors of death and sustained VT like right ventricular hypertrophy and fibrosis. Electrophysiological study can assess risk and guide decisions about implantable cardioverter defibrillator placement.
This presentation discusses how to evaluate shock using echocardiography. It defines shock and describes the main types: hypovolemic, cardiogenic, obstructive, and distributive. Guidelines recommend using echo to evaluate shock. The presentation reviews how to assess left ventricular systolic function, volume status, valvular pathology, and diastolic function. It provides examples of using echo to diagnose specific causes of shock like sepsis, myocardial infarction, pulmonary embolism, and tamponade. The key messages are that echo is very useful for diagnosing and managing shock, and training in point-of-care ultrasound is important.
Cardiac Stress Test vs CT Coronary Angiogram: Which is better?ahvc0858
Cardiac stress tests and CT coronary angiography are effective options for evaluating heart disease, with certain advantages and limitations for each. A cardiac stress test such as a treadmill exercise stress test or stress echocardiogram can detect ischemia by provoking the heart during exercise or pharmacologically, but may have lower sensitivity and specificity than imaging tests. A CT coronary angiogram provides detailed images of the coronary arteries but exposes patients to radiation. The optimal test depends on the individual patient's characteristics, risk factors, and the specific question being answered.
Anaesthetic Management of a Patient with Ischaemic Heart DiseaseZareer Tafadar
This document discusses the anaesthetic management of patients with ischemic heart disease undergoing non-cardiac surgery. It begins by defining ischemic heart disease and outlining its various manifestations including stable angina, unstable angina, and myocardial infarction. It then discusses preoperative evaluation and risk stratification of these patients, including medical history, physical exam, ECG, stress testing, and coronary angiography. Intraoperative management focuses on minimizing myocardial ischemia through beta-blockers, tight blood pressure control, and avoidance of tachycardia or hypotension.
1) Acute myocardial infarction is irreversible necrosis of heart muscle caused by prolonged ischemia and can present as unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) or ST-elevation myocardial infarction (STEMI).
2) UA/NSTEMI is diagnosed based on symptoms of chest pain or discomfort and elevated cardiac biomarkers showing myocardial necrosis.
3) Treatment involves reducing myocardial oxygen demands, improving supply, and risk stratification to determine need for aggressive versus conservative management. High risk patients may receive early invasive procedures while low risk patients can be managed medically.
09. Ischaemia assessments - What, when and which one.pdffarahhanim54
This document discusses various cardiac imaging tests for assessing ischemia, including their advantages and limitations. It provides details on exercise stress electrocardiography (EST), stress echocardiography, nuclear perfusion imaging, cardiac MRI, coronary CT angiography, and invasive coronary angiography. The document recommends that in patients with high likelihood of CAD but normal initial testing, noninvasive functional or anatomical imaging like stress echocardiography or coronary CTA should be the initial test, while invasive angiography may be reasonable for very high risk patients. It emphasizes that selecting the best test depends on factors like diagnostic accuracy need, availability, and patient characteristics.
This document provides an overview of acute coronary syndrome (ACS). It begins with a review of coronary artery anatomy and variations. It then discusses the presentations of ACS, including ischemic chest pain and equivalents. The main types of ACS - unstable angina, NSTEMI, and STEMI - are defined based on symptoms, electrocardiogram findings, and cardiac biomarker levels. Diagnosis and management strategies are outlined, including reperfusion therapies and drug treatments. Follow-up care after ACS and indications for procedures like cardiac catheterization and ICD placement are also summarized.
EMGuideWire's Radiology Reading Room: Hypertrophic CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Hypertrophic Cardiomyopathy and is brought to you by Ashley Moore-Gibbs, DNP, Claire Lawson, NP, Laszlo Littmann, MD, and John Symanski, MD.
This document summarizes information about acute pulmonary embolism (PE):
- PE occurs when a blood clot blocks a pulmonary artery, has nonspecific symptoms, and diagnosis is often delayed. Treatments are effective but prevention is important.
- Risk factors include older age, surgery, trauma, cancer, oral contraceptives, prior clots, obesity, and hereditary conditions. Asians may have a lower risk due to dietary and genetic factors.
- Diagnosis involves considering symptoms, tests like CT scans and D-dimers, and algorithms for diagnosing with varying levels of suspicion. Treatment involves anticoagulants while preventing future clots.
This document discusses mitral valve disease and treatment options. It provides information on:
- Mitral regurgitation (MR), the most common type of heart valve disease, which occurs when the mitral valve does not close properly.
- Treatment options for MR including open-heart surgery, minimally invasive surgery, robotic surgery, and the MitraClip procedure. MitraClip offers a less invasive alternative for high-risk surgical patients.
- Guidelines for referral for mitral valve repair/replacement, focusing on patients with moderate-severe or severe MR who are at high-risk for open-heart surgery.
- The large population of MR patients who are not surgical candidates, representing an unmet
This document summarizes information on device therapy for congestive heart failure, including cardiac resynchronization therapy (CRT). It discusses:
1) The prevalence and mortality rates of heart failure in the US. Up to 30% of CHF patients have intraventricular conduction delays which increase mortality.
2) NYHA heart failure classifications and guidelines for CRT approval for classes III and IV.
3) Clinical trials that demonstrated the benefits of CRT including increased exercise capacity, quality of life, and decreased hospitalizations and mortality.
4) Anatomical challenges of CRT implantation via the coronary sinus and risks of the procedure. Proper lead placement is important to reduce asynchrony.
EMGuideWire's Radiology Reading Room: Stress-Induced CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Stress-Induced Cardiomyopathy and is brought to you by Jenna Pallansch, MD, Claire Lawson, NP, Shelby Hixson, PA, Emily Lipsitz, PA, Ashley Moore-Gibbs, DNP, Laszlo Littmann, MD, and John Symanski, MD.
Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L...Brussels Heart Center
1. Atrial fibrillation and congestive heart failure often occur together, but it is unclear which condition causes the other.
2. Studies show that developing atrial fibrillation after already having congestive heart failure carries a better prognosis than developing congestive heart failure after already having atrial fibrillation.
3. Upstream therapies like ACE inhibitors, statins, and omega-3 fatty acids may help prevent atrial fibrillation and improve outcomes, but data is primarily from retrospective studies. Maintaining sinus rhythm through drugs, cardioversion, or ablation can benefit patients with congestive heart failure, though cardioversion carries risks of embolism.
1. The number of adults with congenital heart disease (ACHD) is growing due to increased survival of children born with CHD. However, there is minimal guidance on managing ACHD patients in the intensive care unit (ICU).
2. A study of 372 ACHD patients admitted to the ICU found longer lengths of stay, higher resource use, and mortality risks compared to non-ACHD patients. Outcomes varied by complexity of heart condition.
3. Managing ACHD patients in the ICU requires understanding their unique cardiac anatomy and physiology to avoid potential harms from standard interventions and assessments. Special considerations are needed for procedures, monitoring, and treatment.
Acute Coronary Syndrome (ACS) encompasses a spectrum of conditions caused by reduced blood flow in the coronary arteries, including unstable angina and myocardial infarction (MI). It is typically diagnosed through a patient's symptoms, electrocardiogram (ECG) findings, and cardiac biomarker levels. For ACS patients presenting within 12 hours of symptoms, guidelines recommend obtaining an ECG within 10 minutes and starting reperfusion therapies like thrombolysis within 30 minutes to minimize heart muscle damage. Diagnosis is based on criteria including typical chest pain, ECG changes, and elevated troponin levels. Outcomes are generally worse in elderly patients and those with atypical presentations and longer treatment delays.
1) Management of ST elevation myocardial infarction (STEMI) at the emergency department is critical as time lost is myocardial lost. The goal is to achieve door-to-needle time of 30 minutes to administer reperfusion therapy like streptokinase.
2) Reperfusion therapy within 30 minutes of arrival at the emergency department can reduce myocardial damage and mortality from STEMI. Hospitals should have a plan to minimize delays and ensure thrombolytic drugs are readily available.
3) Absolute contraindications for thrombolytic therapy include recent bleeding, stroke or surgery. Relative contraindications include uncontrolled high blood pressure and use of anticoagulants. Hospitals need ongoing evaluation to meet time targets for reperfusion therapy.
The document discusses unstable angina and non-ST-elevation myocardial infarction (UA/NSTEMI). It describes the pathophysiology, clinical presentation, diagnosis, and risk stratification of patients presenting with suspected UA/NSTEMI. The diagnostic evaluation involves assessing the likelihood of coronary artery disease, monitoring the patient for recurrent symptoms and checking cardiac biomarkers and electrocardiograms, and may include stress testing to evaluate for significant CAD if the initial workup is inconclusive. Early risk assessment using markers like troponin levels, ST changes, and risk scores can help guide treatment and identify patients most likely to benefit from a more aggressive strategy.
High level review of congenital heart lesions; recommendations for anesthetic management of adults with congenital heart disease for noncardiac surgery
This document provides an overview of acute aortic dissection, including:
- The definition and pathophysiology of acute aortic dissection.
- Risk factors for acute aortic dissection include conditions like Marfan syndrome and known thoracic aortic aneurysms. High-risk symptoms include abrupt onset of severe, ripping chest or back pain.
- Imaging techniques like CT, MRI, and TEE can diagnose acute aortic dissection but no single test is definitive. Early management focuses on hemodynamic stabilization and expediting surgery for type A dissections.
Similar to Out of hospital cardiac arrest - a cardiologist perspective (20)
1) The document discusses treatment guidelines for severe or life-threatening asthma, including the use of intravenous magnesium sulfate, salbutamol, and aminophylline.
2) Guidelines vary between countries in their recommendations for doses and order of administration of these intravenous treatments.
3) The document advocates for faster resolution of bronchospasm through early use of intravenous beta-2 agonists like salbutamol followed by magnesium sulfate to reduce side effects like tachycardia.
Social media in anaesthesia and intensive careoxicm
Social media has both benefits and drawbacks. While it can be useful for keeping in touch with distant loved ones, it can also be a waste of time. FOAM (Free Open Access Medical education) resources are increasingly important as they allow learning from a wide variety of up-to-date sources using multiple mediums like video and audio. However, determining high quality FOAM sources can be challenging.
This document discusses the experience of implementing a paperless system in the intensive care unit (ICU) at the Royal Berkshire NHS Foundation hospital. It describes the barriers faced, such as staff being uncomfortable with computers. The system now allows access to patient records from anywhere, interfaces medical devices, and includes notes, prescriptions, observations and more. The author discusses the need for IT support, dedicated resources and overcoming barriers to create a successful system. The future goals are to use informatics to address care gaps and use data to improve care and reduce adverse events.
The document provides guidance on using reflection in appraisals and revalidation. It outlines the objectives of understanding reflection stages, communicating reflection, and developing action plans. Reflection is presented as an integral part of continuing professional development. The 7 stages of focused reflection are defined, and advantages/disadvantages of directed reflection are discussed. Examples of evidence for competence are gathering feedback, quality improvement activities, and reviewing complaints. Maintaining an up-to-date portfolio is emphasized.
- A respiratory ECMO service was established in the UK in 2011 with 5 centers providing national coverage based on critical care networks. Referrals follow criteria from the CESAR study.
- A case of severe acute respiratory failure is discussed involving retrieval from a local hospital to the Royal Brompton Hospital ECMO center. Preparations for safe transfer and management on ECMO are outlined.
- The document reviews evidence for ECMO in respiratory failure including randomized trials and case series showing improved survival compared to conventional management, especially when initiated earlier in the course.
This document discusses the emergency management of hypercalcaemia. It begins by covering calcium distribution and regulation in the body. It then discusses the main causes of hypercalcaemia, which include primary hyperparathyroidism and tumor-related causes. The clinical features and investigations for hypercalcaemia are outlined. Initial management involves fluid resuscitation and diagnosis. Specific treatments discussed include bisphosphonates, calcitonin, cinacalcet, denosumab, steroids, and dialysis. The treatment goal is to tailor the approach to the underlying cause of hypercalcaemia in each case.
AKI, or acute kidney injury, occurs in 18% of hospital admissions and can be caused by sepsis, hypovolemia, drugs, acute glomerulonephritis, or obstruction. Early signs include increased serum creatinine, low blood pressure under 90, and low urine output under 500ml in 24 hours. Treatment focuses on fluid management and supportive care; starting renal replacement therapy is based on fluid overload and high blood urea levels. Continuous renal replacement therapy is preferred for hemodynamic instability while intermittent hemodialysis enables faster clearance but is riskier for unstable patients.
This document discusses obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS). It covers the definition, symptoms, risk factors, diagnosis through sleep studies, and treatment options including CPAP, weight loss interventions, and non-invasive ventilation. It notes that OSA is common in intensive care unit patients and discusses considerations for managing OSA and obesity in the ICU and perioperative settings.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
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Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
2. • Role of early coronary angiography and
intervention
• Literature review
• Additional considerations
• The King’s Experience
3. • I’m an Interventional Cardiologist
• I don’t particularly like to get up in the middle of the night for
OOHCA arrest patients with so many unknown clinical and
prognostic variables
• I have sympathy with colleagues who question the aetiology, the
diagnostic work-up and early aggressive coronary strategy
• I believe that an artery with 0% stenosis is highly likely to improve
ischaemia and ischaemia-related complications (like VF/VT/LV
dysfunction)
• Can I prove it with Class IA data – No ...
Conflicts of Interest
• ........ And I still believe in therapeutic hypothermia
4. • Incidence of OOHCA in the European population estimated at about 40
per 100,000 per year1
• OOHCA resuscitations by UK Ambulance crews in 2013 ~ 28,000 cases2
(estimated 60,000 call-outs)
• LAS: 80% arrests occur at home, with 20% VF/VT the presenting
rhythm3
• Outcomes in SHR better; mortality increases with every minute delay to
BLS or DCCV4,5
• UK average survival to hospital discharge from decision to resuscitate
8.6% (cf Holland/Seattle/Norway ~20%) 2
• Leading causes of death are CV (acute) and brain injury (late)6,7
1. Atwood C et al. (2005) Incidence of EMS-treated out-of-hospital cardiac arrest in Europe. Resuscitation, 67: 75–80
2. www.england.nhs.uk/statistics/stasistical-work-areas/ambulance-quality-indicators
3. London Ambulance Service Cardiac Arrest Annual Report 2012/2013 [www.londonambulance.nhs.uk].
4. Lindner T et al. Resuscitation 2011; 82:1508-13.
5. 2010 European Resuscitation Council guidelines for resuscitation. Resuscitation 2010;81: 1219-76.
6. Schoenenberger R et al. Survival after failed out-of-hospital resuscitation. Arch Intern Med. 1994;154:2433-7.
7. Laver S et al. Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med 2004;30:2126–2128.
5. • OOHCA is the leading cause of death in IHD patients1
• ‘Obstructive’ coronary anatomy is common in angiographic and post-
mortem series of OOHCA cohorts2-4
> 90% in STEMI / >40% in non-STEMI
• Good data to support early interventional strategy in non-OOHCA
NSTEMI/STEMI5,6
• Little data to guide practice in comotose / I+V patients
- observational / registries / multiple variables
•Observational literature that VT/VF burden reduced in revascularised
ICD patients7,8
1. Zheng Z et al. (2001) Sudden cardiac death in the United States, 1989–1998. Circ.104:2158–2163
2. Spaulding C et al. (1997) Immediate Coronary angiography in survivors of OOHCA. NEJM 1997 336; 1629-1633
3. Davies M (1992) et al. Anatomic features in victims of sudden coronary death: coronary artery pathology. Circ ;85:S I:I-19
4. Dumas F et al.(2010) PROCAT registry. CCI, 3:200-207.
5. 2014 ESC/EACTS Guidelines on Myocardial Revascularisation. Windecker S et al.
6. 2012 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Steg P et al.
7. Cook J et al. Am Heart J 2002; 143(5): 821-6
8. Gillis A et al. Circulation 2007; 116: II_534
6. •2010 International Consensus on Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care1
- ‘reasonable to perform immediate angiography and PCI in“selected”
patients, despite the absence of STEMI or prior clinical findings such as
chest pain
• 2012 ESC Guidelines support immediate CAG +/- revascularisation2
- STEMI (Class IB)
- Suspected ACS irrespective of ECG (Class IIa B)
•2014 Invasive coronary treatment strategies for out-of-hospital cardiac
arrest: a consensus statement from the European association for
percutaneous cardiovascular interventions (EAPCI)/stent for life
(SFL) groups3
1. 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment
Recommendations. Circulation . Hazinski M et al.
2. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: Task Force Statement for
ESC (2012) Steg P et al.
3. Consensus statement from the European association for percutaneous cardiovascular interventions (EAPCI)/stent for life (SFL) groups.
8. Common practice
OOHCA
STEMI PPCI or Lysis
‘Not sure’
‘Could all be reactive ECG
changes’
‘Nothing to hang your hat
on’
‘Lets see if ‘he does’ and
work him up after’
‘Normal’ ECG
Minor ST-segment
changes
Moderate ST-segment or
T wave changes
9. British Cardiac Society (Intervention Sub-group
meeting) 2014
• 56-year old male
• Unprovoked OOHVF arrest
• Known IHD with prior PCI to his LAD following NSTEMI (several
years ago)
• LBBB
• Prompt resuscitation
• Presents to A+E in stable condition / I+V
What would you do now?
10. BCS 2014
• ‘Well – the LBBB could well be old. There’s no clear mandate for
CAG’
• ‘It’s unusual for it to be a primary coronary event if he had no
preceding symptoms’
• ‘There’s certainly not enough evidence to rush in there and
potentially de-stabilise the situation.’
• ‘You cannot tell if this is ischaemia or scar-related arrhythmia from
his old MI’
11. BCS 2014
• Cooled
• Recurrent VF on ICU Day 2
• Commenced on amiodorone and taken to the Cath Labs
• Critical in-stent re-stenosis treated with a single DES in less than a
minute
12. BCS 2014
• Cooled
• Recurrent VF on ICU Day 2
• Taken to the Cath Labs
• Critical in-stent re-stenosis treated with a single DES in less than a
minute
• No further arrhythmias
• Extubated Day 4
• Discharged to wards Day 6
• Home Day 11
13. 3 fundamental questions
• Is coronary disease a likely aetiological factor?
• What evidence is there for early diagnosis/intervention in
an otherwise stabilised patient?
• What harm can an angiogram do?
14. Spaulding CM. N Engl J Med 1997;336:1629-33.
OOHCA associated with high incidence of IHD
Urgent CAG (84)
Normal 17 (20%)
Non-obstructive CAD 7 (8%)
Obstructive CAD 60 (71%)
Single vessel 22
Multivessel 37
Isolated LM 1
Acute Coronary occlusion 40 (48%)
Survivors to hospital in stable condition
101 non-cardiac causes excluded
80% VT/VF
All ECG’s
15. Positive Negative
Chest discomfort
and ST-elevation 87% 61%
Spaulding CM. N Engl J Med 1997;336:1629-33.
Predictive value
Absence of ST-segment elevation does not
exlude acute coronary obstruction
16. Patients post-ROSC admitted to the intensive care unit.
Florence Dumas et al. Circ Cardiovasc Interv. 2010;3:200-207
2003 – 2008
ROSC survivors to admission
All rhythms
PCI to lesions >50%
STEMI All other
17.
18.
19. • Prevalence of CAD is high – but is it causative?
• How can we prove and treat accordingly?
• Is there a role for early invasive angiography +/-
revascularisation?
Evidence for acute invasive strategy?
• No RCT data
• Registry data (>3,500 patients)
• Multivariate analysis of observational registries
22. Resuscitation 2014 85, 88-95DOI: (10.1016/j.resuscitation.2013.07.027)
Shock
LV support
Antiplatelets etc..
32.7%
39.0%
Registry data
754 consecutive comotose ROSC
6 Tertiary care centres
Unclear timeframe/history
VT/VF only
STEMI excluded
Early <24hrs
Late >24hrs
23. In non-STEMI VF/VT arrests:
- 30% of patients had an acute coronary occlusion
- 60-70% had significant bystander disease
- 30-40% went on to have successful PCI
No angiographic differences between early and late CAG
27. CCI, 2010
2003 – 2008
ROSC survivors to admission n=714
PCI to lesions >50%
28. Patients post-ROSC admitted to the intensive care unit.
Florence Dumas et al. Circ Cardiovasc Interv. 2010;3:200-207
2003 – 2008
ROSC survivors to admission
PCI to lesions >50%
29. Florence Dumas et al. Circ Cardiovasc Interv. 2010;3:200-207
Survival rates according to the performance
and outcome of PCI
30. Features associated with survival to hospital discharge
Younger age
Non-DM status
Arrest in public location
Prompt BLS and ROSC
VF/VT presentation
STEMI ECG pattern
Low admission lactate
Therapeutic hypothermia
Successful PCI OR 2.06 (1.16-3.66; p 0.013)
Only ‘successful’ PCI predictive of mortality
benefit after multivariate analysis
Florence Dumas et al. Circ Cardiovasc Interv. 2010;3:200-207
35. Selection bias?
• Patients undergoing early CAG/revascularisation are
generally:
- younger
- better CPC score post-arrest
- more likely to have STEMI
- more likely to have VF/VT
• Similarly, variability between Centres may not take into
account
- sub-specialty input
- access to Ix / treatment options/pathways
- more formalised MDT approach to patient care
38. • STEMI – plaque rupture, heavy thrombus burden, impaired
coronary flow
- clear mandate to restore flow
• Obstructive coronary disease with preserved TIMI flow
- take a view on the complexity of anatomy in conjunction with
the patient and their haemodynamics
- Surgeons rarely taken on emergency CABG in this setting
- Similarly, complex rotablation in heavily calcified vessels or
complex CTO revascularisation NOT an option acutely
No RCT Data
No information about revascularisation strategies from
registry data
Little to guide us on timing (acute vs staged) – except
shock and extent of revascularisation (cf non-comatose
ACS patients)
But worth noting:
PCI revascularisation levels high in STEMI cohorts and
30-50% in non-STEMI groups from registry data
40. What harm can an angiogram do?
*Major bleeding approximately 3.5%
*Peripheral ischaemic complications approx 4-11%
*Stroke rates approx 1%
------------------------------------
Radial vs femoral
Use of adjunctive LV support devices
Variable anticoagulation regimens
*IABP – SHOCK II study, NEJM 2012
Early Revascularization in Acute Myocardial Infarction Complicated by Cardiogenic Shock, NEJM 1999
30-40% CPR/VT/VF
45. LV support devices
• Cardiogenic shock is present in 30-40% of OOHCA survivors
• Presents most often within 4-6 hours of the index event
• No device has shown prognostic benefit in comatose or non-comatose
patients1
• Use of IABP/Impella observational series ranges from 10-42%2
• Higher incidence in patients treated emergently by PCI
• Future Role for Impella CP and/or ECMO...
• Principle of haemodynamic support vs vascular access and longer-term
complications (sepsis, blood dyscrasias etc..)
1. ISAR Shock, IABP-SHOCK I and II, PROTECT II
2. Cheng et al. 2009, Sjauw et al. 2009, Hovdenes et al. 2009
48. Acute Stent Thrombosis
• Acute stent thrombosis occurs in 4.6% - 10.9% of ACS patients
complicated by CA1,2
• OR for AST 12.9 following cardiac arrest (95%CI 1.3-124.6; p=0.027)2
• Mortality with AST is high (up to 45%) 3
• Likely factors - non-administration of antiplatelets / heparins2
- malabsorption and altered metabolism4
- highly procoagulant /inflammatory state
- adverse haemodynamic status
1. Shah N et al. JACC 2015;65(10_S)
2. Joffre J et al. Resuscitation 2014; 85(6):769-73
3. Buchanan G et al. Thrombosis 2012
4. Bjelland T et al. Resuscitation 2010;81:1627–31
50. Cangrelor
• IV P2Y12 ADP receptor antagonist
• High affinity, reversible
• ½ life 3 minutes
• Normal PLT function after 1hr
• Recent FDA approval
51.
52. London Heart Attack Centre Network 2005
Harefield Royal Free Heart London Chest
Imperial
St. George’s
St. Thomas’s
King’s
8 HAC
Approx 30 Acute admission units
7.5/10million people
>600m2
53. • 9,805 OOHCA calls attended by LAS
• Resuscitation attempted for 4,317 patients
- 92% declared dead on scene / 8% DNR in place
• Of those actively treated by LAS:
• Survival to discharge:
2013/2014
48.6% Witnessed
44.8% Bystander CPR performed
31% Sustained ROSC to Hospital admission
85.7% Primary cardiac aetiology
10.3% Witnessed
32.4% Utstein population (witnessed / Vf or VT / presumed cardiac)
47.6% Treated at HAC
58.8% Use of AED
58. OOHCA
Cath
Lab
Resus
ITU
Home
N = 331
N = 146
(44.1%)
N = 185 (55.9%)
N = 47 (25.4 %)
N = 144 (43.5 %)
2011-2014
OOHCA ROSC
Survivors to Cath-Lab +/or ICU
All I+V cases
Total number to
Cath Lab =193
Data - R.Nerla/F.Jouhra
62. OOHCA
Cath Lab sub-group
Cath
Lab
No angio
PCI
AngioN =181
(93.7%)
N = 12 (6.3%)
N = 117
(65%)
No PCI
N = 59 (32.6%)
N = 331
N = 193 (58.3 %)
Futile N = 6
Other diagnosis more probable N = 6
CABG N = 5
STEMI (92%)
nonSTEMI (38%)
Data - R.Nerla/F.Jouhra
63. Cath Lab sub-group
• Multi-vessel intervention 22%
• 15% cardiogenic shock
- IABP 98% / Impella 1% / ECMO 1%
• Survival to ICU 98%
• Survival to hospital discharge:
PCI
AngioN =181
(93.7%)
N = 117
(65%)
STEMI (92%)
nonSTEMI (38%) P <0.001
Data - R.Nerla/F.Jouhra
64. Survival by diagnosis
P <
0.001
* Including all patients with a definite primitive cardiac cause
for OOHCA
Data - R.Nerla/F.Jouhra
Overall survival to discharge 43.5%
Median ICU stay (d) 3 (0-40)
Mean 6.8 + 8.2
Median Hospital stay 6 (0-87)
65. Work to do...
• Follow-up data
Mortality
Neurological outcomes
ICD implantation
• Improving post-arrest care
LV support (ECMO)
Neurocognitive prognostication
Neuro-rehab
Academic integration
66. Summary
• OOHCA is associated with significant mortality and morbidity
• The major gains in survival are likely to evolve through front-
managed patient care
• The prevalence of coronary disease in OOHCA survivors is
significant
• Whether this is causative or not is uncertain – but aggressive multi-
disciplinary patient management – including early coronary
angiography and revascularisation – appears safe and to confer
better survival and neurological outcomes.
Editor's Notes
Patients post-ROSC admitted to the intensive care unit.
Single centre experience in Krakow, Poland 2000 – 2010
Select OOHCA admissions
405 patients admitted for urgent CAG +/- revasc (bias)
30% conscious
First study where – if anything – there was bias towards sicker patients in the early PCI group
However, maybe unknown variables to explain why patients weren’t taken to the lab straight away
Unknown outcomes/effect where non-DCCV rhythms are kept in
Predictors of hospital mortality. Displays a multivariate logistic regression analysis examining predictors of in-hospital mortality. All patients who survived to hospital admission following cardiac arrest due to a ventricular arrhythmia and without ST elevation myocardial infarction on the postresuscitaiton electrocardiogram were included in the analysis (n=269). The model adjusts for study site, age, bystander CPR, shock on admission, pre-arrest chronic medical conditions, eyewitness to arrest, and time to ROSC (minutes). Patients were considered to be previously healthy if they had no known chronic medical conditions prior to the arrest. Early cardiac catheterization (CC) was defined as CC performed either immediately upon hospital admission or during hypothermia treatment, which includes up to 24hours following cardiac arrest. By definition, all patients who received early CC were comatose and their potential for neurologic recovery remained unknown at the time of CC. ROSC=return of spontaneous circulation; CPR=cardiopulmonary resuscitation; PMHx=past medical history.
Patients post-ROSC admitted to the intensive care unit.
Survival rates according to the performance and outcome of PCI. ns indicates not significant.