Adherence to guidelines improves the clinical outcome of patients with acutely decompensated heart failure.

Isr Med Assoc J. 2009 Jun;11(6):348-53

Authors: Braun E, Landsman K, Zuckerman R, Berger G, Meilik A, Azzam ZS, , ,

BACKGROUND: Acutely decompensated heart failure/pulmonary edema is one of the most common medical problems in clinical practice. Approximately 500 patients are admitted to Rambam Health Care Campus yearly with the diagnosis of ADHF/PE. As a result, Rambam established local instructions and guidelines for the treatment of ADHF/PE based on the guidelines published by the American Heart Association, American College of Cardiology and The European Society of Cardiology. OBJECTIVE: To examine whether adherence to guidelines improves the outcome of patients with ADHF/PE in internal medicine wards. METHODS: Data were collected from the charts of 78 patients admitted to Rambam with ADHF/PE and were compared to a matched historic cohort. RESULTS: Echocardiography was performed more commonly in the study group patients as compared to the control group, 85% vs. 37.7% respectively (P = 0.0001). In patients who were treated according to the guidelines, angiotensin-converting enzyme inhibitors and beta-blockers were prescribed more commonly as compared to the control group. The 3 month mortality rate was significantly lower in the study group (P = 0.021). CONCLUSIONS: Adherence to guidelines for treatment of ADHF/PE decreased the short-term mortality and increased the use of medications known to reduce mortality and morbidity in patients with systolic heart failure. Echocardiography is an important tool to guide treatment of ADHF/PE.

PMID: 19697585 [PubMed - indexed for MEDLINE]

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Elevated cardiac troponins: the ultimate marker for myocardial necrosis, but not without a differential diagnosis.

Isr Med Assoc J. 2009 Jan;11(1):50-3

Authors: Inbar R, Shoenfeld Y

Cardiac troponins are released from myocytes following myocardial damage and loss of membrane integrity. Their significance when diagnosing acute myocardial infarction is immense, e.g., their high sensitivity and specificity for myocardial tissue, the prognostic information they bear, and their role in risk stratification and therapeutic decisions. However, one cannot fully and blindly rely on cTn testing in diagnosing acute MI since many other conditions are associated with elevation of troponin. A review of the literature demonstrates a myriad of such examples including non-thrombotic cardiac injury, systemic diseases and laboratory interferences. Failure to acknowledge the differential diagnosis of elevated troponin may lead to over-diagnosis of MI and, accordingly, misdiagnosis of the real cause. It is of utmost importance that all physicians who measure troponin recognize the possibility of falsely diagnosing Ml and are familiar with the main alternative causes for cardiac troponin elevation.

PMID: 19344014 [PubMed - indexed for MEDLINE]

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Efficacy of nebulized fluticasone propionate in adult patients admitted to the emergency department due to bronchial asthma attack.

Isr Med Assoc J. 2008 Aug-Sep;10(8-9):568-71

Authors: Starobin D, Bolotinsky L, Or J, Fink G, Shtoeger Z

BACKGROUND: Locally delivered steroids by inhalers or nebulizers have been shown in small trials to be effective in acute asthma attack, but evidence-based data are insufficient to establish their place as routine management of adult asthma attacks. OBJECTIVES: To determine the efficacy of nebulized compared to systemic steroids in adult asthmatics admitted to the emergency department following an acute attack. METHODS: Adult asthmatics admitted to the ED were assigned in random consecutive case fashion to one of three protocol groups: group 1–nebulized steroid fluticasone (Flixotide Nebules), group 2–intravenous methylprednisolone, group 3–combined treatment by both routes. Objective and subjective parameters, such as peak expiratory flow, oxygen saturation, heart rate and dyspnea score, were registered before and 2 hours after ED treatment was initiated. Steroids were continued for 1 week following the ED visit according to the protocol arm. Data on hospital admission/discharge rate, ED readmissions in the week after enrollment and other major events related to asthma were registered. RESULTS: Altogether, 73 adult asthmatics were assigned to receive treatment: 24 patients in group 1, 23 in group 2 and 26 in group 3. Mean age was 44.4 +/- 16.8 years (range 17-75 years). Peak expiratory flow and dyspnea score significantly improved in group 1 patients compared with patients in the other groups after 2 hours of ED treatment (P = 0.021 and 0.009, respectively). The discharge rate after ED treatment was significantly higher in groups 1 and 3 than in group 2 (P = 0.05). All 73 patients were alive a week after enrollment. Five patients (20.8%) in the Flixotide treatment arm were hospitalized and required additional systemic steroids. Multivariate analysis of factors affecting hospitalization rate demonstrated that severity of asthma (odds ratio 8.11) and group 2 (OD 4.17) had a negative effect, whereas adherence to chronic anti-asthma therapy (OD 0.49) reduced the hospitalization rate. CONCLUSIONS: Our study cohort showed the advantage of nebulized steroid fluticasone versus systemic corticosteroids in adult asthmatics managed in the ED following an acute attack. Both these and previous results suggest that nebulized steroids should be used, either alone or in combination with systemic steroids, to treat adults suffering acute asthma attack.

PMID: 18847151 [PubMed - indexed for MEDLINE]

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