- Email: [email protected]
Predictors of myocardial infarction after an acute coronary syndrome with clopidogrel and prasugrel
Correspondence / American Journal of Emergency Medicine 31 (2013) 1274–1289
Two of the commonly used models: the thrombolysis in myocardial infarction (TIMI) models for STEMI and non–ST-elevation myocardial infarction–ACS and the Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin (eptifibatide) Therapy model predict short-term mortality (up to 30 days) only and the Global Registry of Acute Coronary Events model predicts 6-month mortality following hospital discharge [2-5]. We sought to determinate the new predictors of ACS mortality in the follow-up up to 1 year. We included 415 patients with an ACS and a percutaneous coronary intervention with stent. The 30% were STEMI, and the mortality rate in the follow-up was 2.65%. We made a univariable and a multivariable analysis with the risk factors and other variables to determinate the predictors of mortality in the follow-up up to 1 year. These were hypertension (P = .04), STEMI (P = .04), diabetes (P b .01), age (P b .001), and severe left ventricular dysfunction (P b .0001). We conclude that hypertension and diabetes are very important risk factors in the follow-up of this population because they appear as independent predictors of mortality in the follow-up up to 1 year of an ACS in the multivariable analysis, at the same time that the strong predictors are age and severe left ventricular dysfunction. Diego Conde MD Nicolas Lalor MD Leandro Rodriguez MD Pablo Elissamburu MD Marcelo Trivi MD Instituto Cardiovascular de Buenos Aires – Sanatorio Anchorena Blanco encalada 1543, Buenos Aires, 1428, Argentina E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.05.024
References [1] Bavry AA, Kumbhani DJ, Quiroz R, et al. Invasive therapy along with glycoprotein IIb/IIIa inhibitors and intracoronary stents improves survival in non–ST-segment elevation acute coronary syndromes: a meta-analysis and review of the literature. Am J Cardiol 2004;93:830–5. [2] Eagle KA, Lim MJ, Dabbous OH, et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month post-discharge death in an international registry. JAMA 2004;291:2727–33. [3] Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/nonST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000;284:835–42. [4] Boersma E, Pieper KS, Steyerberg EW, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation 2000;101:2557–67. [5] Morrow DA, Antman EM, Charlesworth A, et al. TIMI risk score for ST-elevation myocardial infarction: a convenient, bedside, clinical score for risk assessment at presentation: an intravenous nPA for treatment of infarcting myocardium early II trial substudy. Circulation 2000;102:2031–7.
Predictors of bleeding in acute coronary syndromes with clopidogrel and prasugrel☆ To the Editor, The use of new antiplatelet drugs as prasugrel in patients with acute coronary syndromes (ACS) reduced the incidence of ischemic events. In many cases, the bleeding increases patient morbidity and mortality [1-5]. The goal of our study was to identify the variables associated with increased risk of bleeding in the follow-up to 1 year in patients with an ACS and a percutaneous angioplasty in the 2 groups. ☆ Conflict of interest: None.
1287
We included all admitted patients with an ACS undergoing coronary angioplasty between January 1, 2012, and December 31, 2012. We analyzed the variables using multiple logistic regression method. Four hundred twenty-two patients were included. The median follow-up was 303days(interquartilerange,25%[211days]to75%[397]days).Fifty-eight patients (12.8%; 95% confidence interval, 9.8-16.5) had bleeding events. Inmultivariateanalysiswithmultiplelogisticregression,independent variables were as follows: age (odds ratio, 1.06 [1.02-1.09]; P = .002), coronary syndromes with ST elevation (odds ratio, 1.99 [1.05-3.79]; P = .03), renal failure (odds ratio, 3.32 [1.62-6.78]; P = .001), and the use of new antiplatelet drug (prasugrel; odds ratio, 4.05 [1.96-8.39]; P b .001). The incidence of bleeding events was high. Patients with coronary syndromes with ST elevation are at increased risk for bleeding. Clinical and laboratory characteristics such as age and renal function are also independent risk variables. The use of new antiplatelet agents, despite being used in younger patients with fewer comorbidities, is strongly associated with higher incidence of bleeding events during follow-up. Leandro Rodriguez MD Diego Conde MD Nicolas Lalor MD Pablo Elissamburu MD Marcelo Trivi MD Instituto Cardiovascular de Buenos Aires–Sanatorio Anchorena Blanco encalada 1543, Buenos Aires, 1428, Argentina E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.05.025
References [1] Kushner FG, Hand M, Smith Jr SC, et al. 2009 Focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009;120: 2271–306. [2] Hamm CW, Bassand JP, Agewall S, et al. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054. [3] Steg PG, James SK, Atar D, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012;33:2569–619. [4] James S, Akerblom A, Cannon CP, et al. Comparison of ticagrelor, the first reversible oral P2Y(12) receptor antagonist, with clopidogrel in patients with acute coronary syndromes: rationale, design, and baseline characteristics of the PLATelet inhibition and patient Outcomes (PLATO) trial. Am Heart J 2009;157:599–605. [5] Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009;361:1045–57.
Predictors of myocardial infarction after an acute coronary syndrome with clopidogrel and prasugrel☆ To the Editor, The use of new antiplatelet drugs such as prasugrel in patients with acute coronary syndromes (ACS) reduced the incidence of ischemic events [1-5]. The goal of our study was to identify the variables associated with increased risk of myocardial infarction (MI) in the follow-up to 1 year in patients with an ACS and a percutaneous angioplasty. ☆ Conflict of interest: None.
1288
Correspondence / American Journal of Emergency Medicine 31 (2013) 1274–1289
We included all admitted patients with an ACS undergoing coronary angioplasty between January 1, 2012, and December 31, 2012. We analyzed the variables using multiple logistic regression method. A total of 414 patients were included. The median follow-up was 303 days (interquartile range 25%: 211 days, 75%: 397 days). The incidence of MI in the follow-up to 1 year was 4.6%. In multivariate analysis with multiple logistic regression, the result was as follows: age, P = .51; diabetes P = .31; coronary syndromes with ST elevation, P = .32; renal failure, P = .37; and the use of clopidogrel, Odds ratio 4.24 (1.21-14.79), P b .01. The incidence of MI was low. The use of clopidogrel as antiplatelet drug was the only independent variable in the multivariate analysis as a predictor of MI in the follow-up. Nicolas Lalor MD Diego Conde MD Leandro Rodriguez MD Pablo Elissamburu MD Marcelo Trivi MD Instituto Cardiovascular de Buenos Aires – Sanatorio Anchorena Blanco Encalada 1543, Buenos Aires, 1428, Argentina E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.05.037
References [1] Kushner FG, Hand M, Smith Jr SC, et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009;120:2271–306. [2] Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054. [3] Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012;33:2569–619. [4] James S, Akerblom A, Cannon CP, et al. Comparison of ticagrelor, the first reversible oral P2Y(12) receptor antagonist, with clopidogrel in patients with acute coronary syndromes: rationale, design, and baseline characteristics of the PLATelet inhibition and patient Outcomes (PLATO) trial. Am Heart J 2009;157:599–605. [5] Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009;361:1045–57.
As for 2 patients referred to the ED due to compromised hemodynamic status with poor image quality (patient 1, obesity; patient 2, excessive lung gas due to chronic obstructive pulmonary disease and mechanical ventilation), POC echocardiogram was used for initial evaluation but failed to produce diagnostically useful image (Fig.). Contrast POC echocardiogram (S5-1 Cardiac Probe with CX50 portable ultrasound; Philips, Andover, MA) was then used to improve the image quality. As showed in Fig., after bolus injection of 2-mL intravenous contrast agent (SonoVue; Bracco, Milan, Italy), left ventricular border was clearly delineated, and excellent image quality was achieved, which largely facilitated the evaluation of cardiac chamber geometry as well as function. Contrast-enhanced ultrasound has been widely used to enable improved endocardial visualization, assessment of left ventricular function, and myocardium perfusion evaluation during state-of-art or stress echocardiogram examination [3]. The safety of echocardiographic contrast agents has also been documented in many large retrospective registries [3]. The risk of an anaphylactoid reaction is only 1:15000, which is much lower than iodinated radiographic contrast agents. As show in our cases, utility of contrast agent in POC echocardiography could also greatly improve the imaging quality of cardiac chamber especially for patient with poor acoustic window, which subsequently increase the accuracy of rapid diagnosis of cardiac pathology in emergency condition. Meanwhile, it could also provide additional information such as regional wall motion and myocardial perfusion defect in those with suspected coronary artery disease in the ED [4]. Study also suggested that contrast enhancement could opacity vascular structures and substantially improves echocardiogram in the diagnosis of aortic dissection and should be considered as the initial imaging modality in emergency setting [5]. Like an old wine in new bottle, contrast-enhanced POC echocardiogram may greatly facilitate rapid and accurate evaluation of cardiac pathology in the ED. Shu Zhang MD Department of Emergency medicine West China Hospital, Sichuan University Chengdu, Sichuan 610041, P.R. China Da Zhu MD Department of Cardiovascular Surgery West China Hospital, Sichuan University Chengdu, Sichuan 610041, P.R. China Zhi Wan MD Yu Cao MD Department of Emergency Medicine West China Hospital, Sichuan University Chengdu, Sichuan 610041, P.R. China E-mail addresses: [email protected]
Old wine in new bottle: utility of contrast-enhanced point-of-care echocardiogram in the ED To the Editor, Point-of-care (POC) echocardiography performed by specialized trained emergency physician using a miniaturized and portable echocardiographic platform is a newly emerged technique, which could largely facilitate the detection of important emergency cardiovascular pathology such as pericardial effusions, cardiac tamponade, massive pulmonary embolism, heart failure, and compromised cardiac function as well as volume deficit [1]. However, because of unique anatomical feature of the heart and its adjacent structure, in a significant proportion of patients, echocardiography fails to produce diagnostically useful images. The main impediments appear to be obesity, lung disease, or under mechanical ventilation at emergency department (ED) [2]. This concern prompted us to use contrastenhanced POC echocardiogram imaging (A common type of diagnosis tool during state-of-art echocardiogram examination) in the ED.
http://dx.doi.org/10.1016/j.ajem.2013.05.038
References [1] Bustam A, Noor Azhar M, Singh Veriah R, et al. Performance of emergency physicians in point-of-care echocardiography following limited training. Emerg Med J 2013Feb 21. (Epub head of print). [2] Mulvagh SL, Rakowski H, Vannan MA, et al. American Society of Echocardiography Consensus Statement on the clinical applications of ultrasonic contrast agents in echocardiography. J Am Soc Echocardiogr 2008;21:1179–201. [3] Senior R, Becher H, Monaghan M, et al. Contrast echocardiography: evidence-based recommendations by European Association of Echocardiography. Eur J Echocardiogr 2009;10:194–212. [4] Wei K. Utility contrast echocardiography in the emergency department. JACC Cardiovasc Imaging 2010;3:197–203. [5] Evangelista A, Avegliano G, Aguilar R, et al. Impact of contrast-enhanced echocardiography on the diagnostic algorithm of acute aortic dissection. Eur Heart J 2010;31:472–9.
Two of the commonly used models: the thrombolysis in myocardial infarction (TIMI) models for STEMI and non–ST-elevation myocardial infarction–ACS and the Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin (eptifibatide) Therapy model predict short-term mortality (up to 30 days) only and the Global Registry of Acute Coronary Events model predicts 6-month mortality following hospital discharge [2-5]. We sought to determinate the new predictors of ACS mortality in the follow-up up to 1 year. We included 415 patients with an ACS and a percutaneous coronary intervention with stent. The 30% were STEMI, and the mortality rate in the follow-up was 2.65%. We made a univariable and a multivariable analysis with the risk factors and other variables to determinate the predictors of mortality in the follow-up up to 1 year. These were hypertension (P = .04), STEMI (P = .04), diabetes (P b .01), age (P b .001), and severe left ventricular dysfunction (P b .0001). We conclude that hypertension and diabetes are very important risk factors in the follow-up of this population because they appear as independent predictors of mortality in the follow-up up to 1 year of an ACS in the multivariable analysis, at the same time that the strong predictors are age and severe left ventricular dysfunction. Diego Conde MD Nicolas Lalor MD Leandro Rodriguez MD Pablo Elissamburu MD Marcelo Trivi MD Instituto Cardiovascular de Buenos Aires – Sanatorio Anchorena Blanco encalada 1543, Buenos Aires, 1428, Argentina E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.05.024
References [1] Bavry AA, Kumbhani DJ, Quiroz R, et al. Invasive therapy along with glycoprotein IIb/IIIa inhibitors and intracoronary stents improves survival in non–ST-segment elevation acute coronary syndromes: a meta-analysis and review of the literature. Am J Cardiol 2004;93:830–5. [2] Eagle KA, Lim MJ, Dabbous OH, et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month post-discharge death in an international registry. JAMA 2004;291:2727–33. [3] Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/nonST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000;284:835–42. [4] Boersma E, Pieper KS, Steyerberg EW, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation 2000;101:2557–67. [5] Morrow DA, Antman EM, Charlesworth A, et al. TIMI risk score for ST-elevation myocardial infarction: a convenient, bedside, clinical score for risk assessment at presentation: an intravenous nPA for treatment of infarcting myocardium early II trial substudy. Circulation 2000;102:2031–7.
Predictors of bleeding in acute coronary syndromes with clopidogrel and prasugrel☆ To the Editor, The use of new antiplatelet drugs as prasugrel in patients with acute coronary syndromes (ACS) reduced the incidence of ischemic events. In many cases, the bleeding increases patient morbidity and mortality [1-5]. The goal of our study was to identify the variables associated with increased risk of bleeding in the follow-up to 1 year in patients with an ACS and a percutaneous angioplasty in the 2 groups. ☆ Conflict of interest: None.
1287
We included all admitted patients with an ACS undergoing coronary angioplasty between January 1, 2012, and December 31, 2012. We analyzed the variables using multiple logistic regression method. Four hundred twenty-two patients were included. The median follow-up was 303days(interquartilerange,25%[211days]to75%[397]days).Fifty-eight patients (12.8%; 95% confidence interval, 9.8-16.5) had bleeding events. Inmultivariateanalysiswithmultiplelogisticregression,independent variables were as follows: age (odds ratio, 1.06 [1.02-1.09]; P = .002), coronary syndromes with ST elevation (odds ratio, 1.99 [1.05-3.79]; P = .03), renal failure (odds ratio, 3.32 [1.62-6.78]; P = .001), and the use of new antiplatelet drug (prasugrel; odds ratio, 4.05 [1.96-8.39]; P b .001). The incidence of bleeding events was high. Patients with coronary syndromes with ST elevation are at increased risk for bleeding. Clinical and laboratory characteristics such as age and renal function are also independent risk variables. The use of new antiplatelet agents, despite being used in younger patients with fewer comorbidities, is strongly associated with higher incidence of bleeding events during follow-up. Leandro Rodriguez MD Diego Conde MD Nicolas Lalor MD Pablo Elissamburu MD Marcelo Trivi MD Instituto Cardiovascular de Buenos Aires–Sanatorio Anchorena Blanco encalada 1543, Buenos Aires, 1428, Argentina E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.05.025
References [1] Kushner FG, Hand M, Smith Jr SC, et al. 2009 Focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009;120: 2271–306. [2] Hamm CW, Bassand JP, Agewall S, et al. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054. [3] Steg PG, James SK, Atar D, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012;33:2569–619. [4] James S, Akerblom A, Cannon CP, et al. Comparison of ticagrelor, the first reversible oral P2Y(12) receptor antagonist, with clopidogrel in patients with acute coronary syndromes: rationale, design, and baseline characteristics of the PLATelet inhibition and patient Outcomes (PLATO) trial. Am Heart J 2009;157:599–605. [5] Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009;361:1045–57.
Predictors of myocardial infarction after an acute coronary syndrome with clopidogrel and prasugrel☆ To the Editor, The use of new antiplatelet drugs such as prasugrel in patients with acute coronary syndromes (ACS) reduced the incidence of ischemic events [1-5]. The goal of our study was to identify the variables associated with increased risk of myocardial infarction (MI) in the follow-up to 1 year in patients with an ACS and a percutaneous angioplasty. ☆ Conflict of interest: None.
1288
Correspondence / American Journal of Emergency Medicine 31 (2013) 1274–1289
We included all admitted patients with an ACS undergoing coronary angioplasty between January 1, 2012, and December 31, 2012. We analyzed the variables using multiple logistic regression method. A total of 414 patients were included. The median follow-up was 303 days (interquartile range 25%: 211 days, 75%: 397 days). The incidence of MI in the follow-up to 1 year was 4.6%. In multivariate analysis with multiple logistic regression, the result was as follows: age, P = .51; diabetes P = .31; coronary syndromes with ST elevation, P = .32; renal failure, P = .37; and the use of clopidogrel, Odds ratio 4.24 (1.21-14.79), P b .01. The incidence of MI was low. The use of clopidogrel as antiplatelet drug was the only independent variable in the multivariate analysis as a predictor of MI in the follow-up. Nicolas Lalor MD Diego Conde MD Leandro Rodriguez MD Pablo Elissamburu MD Marcelo Trivi MD Instituto Cardiovascular de Buenos Aires – Sanatorio Anchorena Blanco Encalada 1543, Buenos Aires, 1428, Argentina E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.05.037
References [1] Kushner FG, Hand M, Smith Jr SC, et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009;120:2271–306. [2] Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054. [3] Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012;33:2569–619. [4] James S, Akerblom A, Cannon CP, et al. Comparison of ticagrelor, the first reversible oral P2Y(12) receptor antagonist, with clopidogrel in patients with acute coronary syndromes: rationale, design, and baseline characteristics of the PLATelet inhibition and patient Outcomes (PLATO) trial. Am Heart J 2009;157:599–605. [5] Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009;361:1045–57.
As for 2 patients referred to the ED due to compromised hemodynamic status with poor image quality (patient 1, obesity; patient 2, excessive lung gas due to chronic obstructive pulmonary disease and mechanical ventilation), POC echocardiogram was used for initial evaluation but failed to produce diagnostically useful image (Fig.). Contrast POC echocardiogram (S5-1 Cardiac Probe with CX50 portable ultrasound; Philips, Andover, MA) was then used to improve the image quality. As showed in Fig., after bolus injection of 2-mL intravenous contrast agent (SonoVue; Bracco, Milan, Italy), left ventricular border was clearly delineated, and excellent image quality was achieved, which largely facilitated the evaluation of cardiac chamber geometry as well as function. Contrast-enhanced ultrasound has been widely used to enable improved endocardial visualization, assessment of left ventricular function, and myocardium perfusion evaluation during state-of-art or stress echocardiogram examination [3]. The safety of echocardiographic contrast agents has also been documented in many large retrospective registries [3]. The risk of an anaphylactoid reaction is only 1:15000, which is much lower than iodinated radiographic contrast agents. As show in our cases, utility of contrast agent in POC echocardiography could also greatly improve the imaging quality of cardiac chamber especially for patient with poor acoustic window, which subsequently increase the accuracy of rapid diagnosis of cardiac pathology in emergency condition. Meanwhile, it could also provide additional information such as regional wall motion and myocardial perfusion defect in those with suspected coronary artery disease in the ED [4]. Study also suggested that contrast enhancement could opacity vascular structures and substantially improves echocardiogram in the diagnosis of aortic dissection and should be considered as the initial imaging modality in emergency setting [5]. Like an old wine in new bottle, contrast-enhanced POC echocardiogram may greatly facilitate rapid and accurate evaluation of cardiac pathology in the ED. Shu Zhang MD Department of Emergency medicine West China Hospital, Sichuan University Chengdu, Sichuan 610041, P.R. China Da Zhu MD Department of Cardiovascular Surgery West China Hospital, Sichuan University Chengdu, Sichuan 610041, P.R. China Zhi Wan MD Yu Cao MD Department of Emergency Medicine West China Hospital, Sichuan University Chengdu, Sichuan 610041, P.R. China E-mail addresses: [email protected]
Old wine in new bottle: utility of contrast-enhanced point-of-care echocardiogram in the ED To the Editor, Point-of-care (POC) echocardiography performed by specialized trained emergency physician using a miniaturized and portable echocardiographic platform is a newly emerged technique, which could largely facilitate the detection of important emergency cardiovascular pathology such as pericardial effusions, cardiac tamponade, massive pulmonary embolism, heart failure, and compromised cardiac function as well as volume deficit [1]. However, because of unique anatomical feature of the heart and its adjacent structure, in a significant proportion of patients, echocardiography fails to produce diagnostically useful images. The main impediments appear to be obesity, lung disease, or under mechanical ventilation at emergency department (ED) [2]. This concern prompted us to use contrastenhanced POC echocardiogram imaging (A common type of diagnosis tool during state-of-art echocardiogram examination) in the ED.
http://dx.doi.org/10.1016/j.ajem.2013.05.038
References [1] Bustam A, Noor Azhar M, Singh Veriah R, et al. Performance of emergency physicians in point-of-care echocardiography following limited training. Emerg Med J 2013Feb 21. (Epub head of print). [2] Mulvagh SL, Rakowski H, Vannan MA, et al. American Society of Echocardiography Consensus Statement on the clinical applications of ultrasonic contrast agents in echocardiography. J Am Soc Echocardiogr 2008;21:1179–201. [3] Senior R, Becher H, Monaghan M, et al. Contrast echocardiography: evidence-based recommendations by European Association of Echocardiography. Eur J Echocardiogr 2009;10:194–212. [4] Wei K. Utility contrast echocardiography in the emergency department. JACC Cardiovasc Imaging 2010;3:197–203. [5] Evangelista A, Avegliano G, Aguilar R, et al. Impact of contrast-enhanced echocardiography on the diagnostic algorithm of acute aortic dissection. Eur Heart J 2010;31:472–9.