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A Consensus on Cath Lab Patient Flow

The atmosphere of a catheterization laboratory poses challenges to maintaining and prioritizing high-quality care and patient safety. Despite these challenges, healthcare providers performing procedures in the cath lab are expected to maintain appropriate communication, clinical management, documentation, and universal protocol. A Uniform Standard for Cath Labs My colleagues and I, on behalf of the Society for Cardiovascular Angiography and Interventions (SCAI), published a clinical expert consensus statement on best practices in the cardiac cath lab in the March 20, 2012 online issue of Catheterization and Cardiovascular Interventions. Previous standards from the American College of Cardiology and SCAI have focused on how to set up a cath lab and run it as an administrator, but the new consensus statement focuses on the processes of patient flow. Following cardiac catheterization, careful patient monitoring is crucial during the hospital stay. Several vital components should be reviewed and documented prior to performing cardiac catheterization. Because percutaneous procedures are often complex, patients should be well informed about the procedure and their possible outcomes. When patients arrive at the cath lab, it’s recommended that a checklist be filled out documenting informed consent, history and physical exam information, medications, and allergies. It’s also important to document each patient’s candidacy for drug-eluting stents as well as sedation and anesthesia, their healthcare proxy status, and results of laboratory evaluations that are needed prior to the procedure. It’s highly recommended that use of any checklists cover all the nuances that can be easily missed if they’re not properly recorded. The SCAI recommends that best practices during cardiac catheterization include a thorough review of patient medical records, access site concerns,...

Managing Recent-Onset Atrial Fibrillation in the ED

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance. AF is a risk factor for ischemic stroke and heart failure, both of which represent significant public health problems. With an increasing prevalence among an aging population, symptomatic AF-related ED visits have been rising and will likely continue to rise. Traditionally, ED patients thought to have recent-onset AF have been hospitalized for monitoring and evaluation of more serious conditions. More recently, clinicians have been utilizing a more aggressive approach in which stable ED patients with presumed recent-onset AF are treated with elective cardioversion without anticoagulation. While previous reports suggest that this approach is associated with a high rate of cardioversion to sinus rhythm and a low rate of hospitalization and complications, there is no consensus on whether it is better than traditional approaches. Seeking Confirmation on Recent-Onset AF Treatment In the February 2012 Journal of Emergency Medicine, David R. Vinson, MD, and colleagues published a prospective multicenter study that describes the management of ED patients with presumed recent-onset AF. “It had been our anecdotal experience at three affiliated community EDs that taking an aggressive cardioversion approach to managing patients with recent-onset AF was effective and associated with few complications,” says Dr. Vinson. “In this study, we put our practice patterns under critical scrutiny to confirm the safety and effectiveness of ED cardioversion and to accurately measure the incidence of thromboembolism 30 days after discharge.” “Clinicians who are already practicing a more aggressive approach to restoring sinus rhythm can be reassured by the safety and efficacy that was observed in our study.” Dr. Vinson and colleagues analyzed 206 patients...

Reducing Triglyceride Levels in Patients at Risk for CVD

Almost one-third of adults in the United States have elevated triglyceride levels (>150 mg/dL), and these levels are continuing to rise in adults aged 20 to 49 at rates that mirror those of obesity and diabetes diagnoses among the young. Observational and epidemiologic studies have demonstrated that high triglycerides (200-500 mg/dL) are associated with increased risk of cardiovascular disease (CVD), with the highest levels (≥1,000 mg/dL) associated with an increased risk of pancreatitis. “High triglyceride levels indicate that patients have high levels of circulating cholesterol-rich remnants,” explains Michael Miller, MD. “Cholesterol-rich remnants are highly atherogenic.” Dr. Miller chaired an American Heart Association (AHA) writing committee that published a scientific statement on triglycerides and CVD in the April 18, 2011 issue of Circulation. “There has been little consensus in the literature about the role of triglycerides in coronary disease,” he says. “There has been no detailed statement on triglycerides that has systematically reviewed both the pathophysiologic and clinical trial evidence to date. For this reason, the AHA felt it was necessary to educate healthcare providers about the importance of triglycerides as a biomarker of cardiovascular risk.” He adds that the 2011 AHA position statement analyzed more than 500 international studies from the past 30 years. Helpful Strategies in Reducing Triglycerides Dr. Miller says it is well known that dietary and other lifestyle interventions can help patients lose weight and have a strong effect on triglyceride levels. “These improvements also translate into salutary effects on systolic blood pressure and glucose, reduced insulin resistance, and systemic inflammation, thereby resulting in an improved metabolic profile.” According to the guidelines, substituting unsaturated dietary fats...

Keys to Transradial Access for Percutaneous Revascularization

Although the adoption of radial coronary angiography and radial PCI in the United States lags behind that of other countries, particularly those in Europe and Asia, transradial coronary intervention has seen an 8% to 10% increased utilization in the U.S., a trend that is expected to continue. The Society for Cardiovascular Angiography and Interventions (SCAI) published an executive summary on transradial access (TRA) for coronary and peripheral procedures in the November 2011 issue of Catheterization and Cardiovascular Interventions. The overview examined utility, utilization, and training aspects to consider when performing angioplasty via the radial artery. “Historically, the traditional route to access blocked coronary arteries has been through the larger femoral artery,” says Ronald P. Caputo, MD, FACC, FSCAI, lead author of the SCAI paper. “TRA is advantageous to transfemoral access because it’s less invasive and has been shown to decrease the risk of access site complications and bleeding.” TRA also is preferred by the vast majority of patients because, unlike the transfemoral approach, it causes less discomfort and allows them to stand up and ambulate immediately following the procedure. In addition, some patients undergoing TRA procedures can be discharged the same day. “These advantages ultimately can decrease length of stay and reduce hospitalization costs while still improving clinical outcomes,” adds Dr. Caputo. Avoiding Complications in Transradial Access Appropriate patient selection for TRA is the first important step in a successful procedure, says Dr. Caputo. Ideal patients for TRA include those with a palpably large radial artery with a strong pulse and a normal Allen’s test with no history of an ipsilateral brachial procedure. Contraindications include abnormal Allen’s test, a...
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