1. CCU Conference 8/18/11 MRN# 0001171164 Naveen Anand Seecheran, M.D. FAHC/UVM Cardiology F1

2. Memorable Cardiology Quotes “Angioplasties are a little like potato chips. You can’t have just one!” -William Castelli, M.D. Former Medical Director, F.C.I. Franklin BA. Am J Cardiol. 2009 Feb 1;103(3):428-30. Epub 2008 Nov 19. Accessed: 8-16-2011.

3. Case Presentation PI & HPI Octogenarian WM –CP/DOE x 2 days –Malaise MHx & SHx –Remote DVTs/PEs (>10y ago) ?Coumadin Therapy –HTN –HLD –CKD Stage II-III

4. Case Presentation SoHx –Occasional etOH, lifelong non-smoker –Widower, (wife died few months earlier) –No PCP –No Cardiologist –No Insurance FHx –No premature CAD & SCD MedHx –Warfarin 5mg –Metoprolol Tartrate 25mg q12h –Simvastatin 40 mg

5. Case Presentation PE: –VS BP 130s/80s, P 100s, RR 20s, spO2 97% 3L NC –AAOX3, GCS 15 –S1 S2 O M/R/G/H/CB/5cm JVD –Bibasilar Crackles –S/NT/ND 0 M BS+ve –0 CNS Deficit –Pulses ++ btl 0 C/E/C –Killip T, Kimball JT (Oct 1967). "Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients". Am J Cardiol. 20 (4): 457– 64. doi:10.1016/0002-9149(67)90023-9. PMID 6059183. Accessed 8-16-2011.

8. Case Presentation Assessment ACS-STEMI DeWood MA, Spores J, Notske R, et al. Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction. N Engl J Med.1980;303(16):897-902. Antman EM, Anbe DT, Armstrong PW, et al. ACC/ AHA guidelines for the management of patients with ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation. 2004;110(5): 588-636. GRACE 30% M(IP), 50% M(6mo)

9. Case Presentation CEs: –Troponin I 0.1 –CK 43 CXR: btl Pl. Effs. Hgb:13.7 WCC:13 (G 60%, B 0%) Cr:2.7 CrCl:23 Levey AS, Greene T, Kusek JW, et al. A simplified equation to predict glomerular filtration rate from serum creatinine (Abstr) J Am Soc Nephrol 2000;(11):155A Accessed 8-16-2011.

10. Case Presentation LHC: –LM: nl –LAD: 50% mid, 50% D1 –LCFx: Small, 80% –RCA: 80% PDA –LVEDP: 15 –AVG: None –LVG: 70%

11. STEMI Mimics

13. Clinical Controversy

14. Results: –2213 activations during 12/08-05/09 –18% were canceled prior to catheterization Cancelation: –ECG Re-interpretation 9% –Not a cath. candidate 4% –Expired 1% –CP/ST resolution 2% –Other 4% 88% were found to have an acute coronary artery occlusion Conclusions: –Low cancelation rate –Systematic cath. laboratory activation by emergency personnel is feasible and accurate –Standard for STEMI system performance

15. Clinical Controversy

16. Results: –1335 patients with suspected STEMI underwent angiography –14% (CI 12.2%-16.0%) had no culprit coronary artery –9.5% (CI 8.0%-11.2%) did not have significant CAD –Cardiac biomarker levels were negative in 11.2% (CI 9.6%- 13.0%) –Combination of no culprit artery with negative cardiac biomarker present in 9.2% (CI 7.7%-10.9%) Conclusions: –Frequency of false-positive cardiac catheterization laboratory activation for suspected STEMI is relatively common in community practice, depending on the definition of false-positive –Recent emphasis on rapid D2B times must also consider the consequences of false-positive catheterization laboratory activation

18. Acute Pericarditis NSAIDs –Ibuprofen Preferred AE Profile Improved CBF Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH (2004). "Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology". Eur Heart J 25 (7): 587–10. doi:10.1016/j.ehj.2004.02.002. PMID 15120056. –ASA –Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R (2004). "Day-hospital treatment of acute pericarditis: a management program for outpatient therapy". J Am Coll Cardiol 43 (6): 1042–6. doi:10.1016/j.jacc.2003.09.055. PMID 15028364.

19. Recurrent Pericarditis Colchicine (Recurrence) –Adler Y, Zandman-Goddard G, Ravid M, Avidan B, Zemer D, Ehrenfeld M, Shemesh J, Tomer Y, Shoenfeld Y (1994). "Usefulness of colchicine in preventing recurrences of pericarditis". Am J of Cardiol 73 (12): 916–7. doi:10.1016/0002-9149(94)90828-1. PMID 8184826. –Imazio M, Bobbio M, Cecchi E, Demarie D, Demichelis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghisio A, Belli R, Trinchero R (2005). "Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial". Circulation 112 (13): 2012–6. doi:10.1161/CIRCULATIONAHA.105.542738. PMID 16186437. –Imazio M, Bobbio M, Cecchi E, Demarie D, Pomari F, Moratti M, Ghisio A, Belli R, Trinchero R (2005). "Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial". Arch Intern Med 165 (17): 1987–91. doi:10.1001/archinte.165.17.1987. PMID 16186468. Steroids –? More AEs, recurrences, and hospitalizations