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Sponsored by Elsevier ClinicalKey Improving Clinical Decisions and Processes : How to get better answers faster to challenging questions in cardiology.

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Presentation on theme: "Sponsored by Elsevier ClinicalKey Improving Clinical Decisions and Processes : How to get better answers faster to challenging questions in cardiology."— Presentation transcript:

1 Sponsored by Elsevier ClinicalKey Improving Clinical Decisions and Processes : How to get better answers faster to challenging questions in cardiology ESC 2012, Satellite Symposium – 26 August 2012

2 Sponsored by Elsevier ClinicalKey Agenda  13:00 Introduction.  Prof. Dr. Stephan Achenbach Universitätsklinikum Erlangen Medizinische Klinik 2, DE  13:10 Getting better answers faster in a challenging cardiology case  Dr Michael H Crawford Professor of Medicine, UCSF  Jon Hickey e-Clinical Reference & Clinical Decision Support, Elsevier  13:30 Q&A  13.45 Symposium Close 2

3 Growth of Medical Knowledge 3 http://www.healthcare.uiowa.edu/2020/index.html

4 Growth of Medical Knowledge 4 Gillam M et al http://research.microsoft.com/en-us/collaboration/fourthparadigm/4th_paradigm_book_part2_gillam.pdf 1 million articles per year expected in 2012 Medical specialists would need 21 hours of reading a day to stay current

5 Where to turn for Knowledge? 5 60 pages 120/270 references ≤ 3 years old

6 How often do Doctors Look for Information? 6 In an average week, information sources are consulted up to five times to support diagnosis and treatment Hospital Physician Information Survey [UK: 100 Clinicians] Conducted by Opinion Health on behalf of ClinicalKey

7 Where do they turn? 7 Most used information source (Q3a) Rating mean score for each source (Q3b-d) Journals Google Clinical Search Engine Textbooks Peers Hospital Physician Information Survey [UK: 100 Clinicians] Conducted by Opinion Health on behalf of ClinicalKey

8 What are the Frustrations? 8 Hospital Physician Information Survey [UK: 100 Clinicians] Conducted by Opinion Health on behalf of ClinicalKey

9 The Challenge How can information be Current Comprehensive Concise Reliable and readily accessible?

10 Sponsored by Elsevier ClinicalKey Agenda  13:00 Introduction.  Prof. Dr. Stephan Achenbach Universitätsklinikum Erlangen Medizinische Klinik 2, DE  13:10 Getting better answers faster in a challenging cardiology case  Dr Michael H Crawford Professor of Medicine, UCSF  Jon Hickey e-Clinical Reference & Clinical Decision Support, Elsevier  13:30 Q&A  13.45 Symposium Close 10

11 Sponsored by Elsevier ClinicalKey Users & Workflows in Cardiology

12 Sponsored by Elsevier ClinicalKey Clinical Case (1/3)  72 year old woman presents with worsening fatigue, ankle edema, abdominal bloating & dyspepsia for 6 months.  Fatigue started 3 years ago when echocardiogram showed  normal biventricular size & function  mild mitral regurgitation  mild to moderate tricuspid regurgitation  mildly enlarged atria  Doppler findings consistent with impaired left ventricular relaxation and elevated filling pressures.  Treated with a thiazide diuretic.  No other significant past history. 12

13 Sponsored by Elsevier ClinicalKey Clinical Case (2/3)  Physical examination  blood pressure of 134/70, heart rate of 89 irregular  clear lung fields  jugular venous pressure of 12cm with a prominent v wave.  apical impulse not palpable  slight right ventricular tap along left sternal border, first & second heart sounds were normal  fourth heart sound & grade 2/6 pansystolic mumur at lower left sternal border that increased in intensity with inspiration  Liver edge palpable & tender  Abdomen distended  2+ lower leg edema. 13

14 Sponsored by Elsevier ClinicalKey Clinical Case (3/3)  Initial laboratory work  mildly elevated liver function tests, BNP of 279, INR of 1.4, creatinine of 1.1  ECG  atrial fibrillation with average rate of 86, but no other abnormalities  Echocardiogram  normal left ventricular size and function  mildly dilated right ventricle with normal function  marked bilateral atrial enlargement  mild mitral & severe tricuspid regurgitation, with normal valve anatomy  Diastolic function  could not be determined due to atrial fibrillation  estimated PASP is 52 mmHg and LVOT VTI is low 14

15 Sponsored by Elsevier ClinicalKey Tricuspid regurgitation 15 Source: Indian J Endocrinol Metab. 2011 Apr-Jun; 15(2): 137–139, Mohammad Hayat Bhat et al. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3125005/

16 Sponsored by Elsevier ClinicalKey Treatment plan - questions?  Treatment with loop diuretic  Improved edema & abdominal distention, but fatigued remained especially on exertion, and low appetite.  Treament with beta blocker  Increased fatigued so stopped  Cardioversion rejected as therapeutic option due to atrial sizes  Questions:  Medical therapy for significant tricuspid regurgitation?  Indications for surgery in significant tricuspid regurgitation, possibly due to annular dilatation and right atrial dilatation?  If surgery contemplated - repair, annuloplasty, biologic valve, or mechanical valve? 16

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18 Sponsored by Elsevier ClinicalKey 18 Elsevier ClinicalKey: 2012 Editorial Advisory Board David Goldmann, M.D., FACP, Board Chair Michael H. Crawford, M.D. (Cardiovascular Disease). Joseph Ming Wah Li, M.D. (Hospital Medicine) Jay S. Duker, M.D. (Ophthalmology) Hugh C. Hemmings Jr., M.D., PhD (Anesthesiology, Pharmacology) Frank H. Miller, M.D. (Radiology) Thomas Moore, M.D. (Obstetrics & Gynecology/Reproductive Medicine) M. Blair Marshall, M.D. (Thoracic Surgery) Bonita Stanton, M.D. (Pediatrics) Denne Thomas-Patterson, M.D. (Family Medicine) Stephen R. Thompson, M.D., MEd, FRCSC (Orthopedic Surgery/Sports Medicine) Todd W. Thomsen, M.D. (Emergency Medicine) Leonard S. Lilly, M.D. (Cardiovascular Disease)

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26 Tricuspid Annular Dilation (A) Normal tricuspid valve. (B) Asymmetric dilation and deformation of the tricuspid annulus leading to tricuspid regurgitation. A = anterior leaflet; P = posterior leaflet; S = septal leaflet. The Growing Clinical Importance of Secondary Tricuspid Regurgitation Taramasso, Maurizio, MD, JACC (Journal of the American College of Cardiology), Volume 59, Issue 8, 703-710 Copyright © 2012 American College of Cardiology Foundation

27 Kay Repair Technique (A) Tricuspid valve bicuspidization is accomplished by plicating the annulus along the posterior leaflet. (B) The sutures are tied, obliterating the posterior leaflet, creating a bicuspid valve. Figure illustration by Craig Skaggs. Figure illustration by Craig Skaggs. The Growing Clinical Importance of Secondary Tricuspid Regurgitation Taramasso, Maurizio, MD, JACC (Journal of the American College of Cardiology), Volume 59, Issue 8, 703-710 Copyright © 2012 American College of Cardiology Foundation

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32 Sponsored by Elsevier ClinicalKey 32 61 pts isolated severe TR had surgery 93% had previous left valve surgery Operative mortality 10% Long term 3 died and 6 were rehospitalized for cardiovascular problems Over 32 months follow up 75% event free survival 61% improved their functional class Predictors of good outcome: RV area 11

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37 Sponsored by Elsevier ClinicalKey 37  Small, retrospective, observational study of the results of TV annuloplasty for functional TR  Assumption: Annular dilatation is the major cause of function TR  Predictors of residual TR (mod-severe) at one year: Preop LVEF <37% and Tethering of the TV  Predictors of hospital discharge residual TR: EF and preop TR severity  Severity of TR during follow-up related to RV pressure

38 Sponsored by Elsevier ClinicalKey Clinical Case Conclusions  In support of surgery: Symptomatic despite medical therapy Severe tricuspid regurgitation Mild pulmonary hypertension Mildly dilated RV with normal function Normal TV anatomy Normal LV systolic function No previous cardiac surgery No significant co-morbidities 38

39 Sponsored by Elsevier ClinicalKey Agenda  13:00 Introduction.  Prof. Dr. Stephan Achenbach Universitätsklinikum Erlangen Medizinische Klinik 2, DE  13:10 Getting better answers faster in a challenging cardiology case  Dr Michael H Crawford Professor of Medicine, UCSF  Jon Hickey e-Clinical Reference & Clinical Decision Support, Elsevier  13:30 Q&A  13.45 Symposium Close 39

40 Sponsored by Elsevier ClinicalKey Improving Clinical Decisions and Processes : How to get better answers faster to challenging questions in cardiology ESC 2012, Satellite Symposium – 26 August 2012


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