BNP: Data, Diagnosis and Applications

Cardiology, CCU Rotation, Respiratory, Why We Do What We Do
BNP: Data, Diagnosis and Applications M Lamberta PGY-3   What are the Biomarkers? [caption id="attachment_3101" align="alignright" width="559"] ACEP Clinical Policy[/caption] Natriuretic Peptide (NP) assays gained approval by the FDA around the year 2000 for the evaluation of undifferentiated dyspnea and suspected ADHF.  The first commercially available test detected the biologically active hormone BNP, but many more recent assays also detect the inert Amino-terminal cleavage product of the BNP prohormone: N-Terminal proBNP (NT-proBNP). (Table 1)  Both biomarkers are comparable in their diagnostic accuracy demonstrated by Receiver Operating Characteristic (ROC) curves.    From 1999 to 2000, Maisel et al. recruited 1,586 participants in the first large multinational randomized control trial (RCT) to evaluate BNP for the diagnosis of heart failure in ED patients presenting with acute dyspnea.[1].  The Breathing Not Properly (BNP)…
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Cancel the Cath Lab Activation; Its only an NSTEMI

Cardiology, CCU Rotation, EBM, residents
By Andrew Barbera, PGY3 Who Needs a Cath?   63 year old male with history of HTN, OA s/p R hip replacement, PTSD was BIBEMS after syncopal event. Pt states that evening he felt acute general weakness when he was on the subway. The weakness worsened when he got off the subway and was walking in the street. He then developed acute severe SOB and he stopped and rested himself on the trunk of a car. Pt then lost consciousness and awoke in the ambulance. Pt stated upon awakening he was alert and oriented. Pt denied CP, palpitations, diaphoresis or dizziness before passing out or during initial ED evaluation. Pt also denied any recent exercise intolerance, recent chest pain, orthopnea or additional symptoms. Pt reported normal stress test done 6…
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Why Not Dobutamine?

Cardiology, CCU Rotation, EBM, Why We Do What We Do
Why Not Dobutamine? PGY3 Neil McCormack   A patient rolls into the emergency room. You don’t need this. You’ve got a lot of other patients. This patient however is in shock. They are hypotensive and with a decreased mental status. You need to give them something and the attending asks what vasopressors you would like. “Why not dobutamine” the intern asks. With a sigh and a heavy eye roll you turn away. But… Why not dobutamine?                 Dobutamine is a synthetic catecholamine used primarily for cardiac stress testing outside of the hypotensive patient (8). This is due to the positive inotropic effects it plays on the heart. Dobutamine acts via a 3:1 selective agonist effect on β1 and β2 receptors respectively. This causes…
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Which came first: the AFib or the MI?

Cardiology, CCU Rotation
Which came first: the atrial fibrillation or the MI? Anna Meyendorff, MD PGY-3 (Image from: http://www.thestar.com/content/dam/thestar/life/2010/07/15/science_answers_the_question_which_came_first_the_chicken_or_the_egg/lichickenoreggjpg.jpeg.size.xxlarge.letterbox.jpeg)   Initial Presentation: 77yo AA F hx HTN, DM, CVA, former smoker presenting with chest pain. Symptoms started 24 hours prior to ED presentation while watching TV. Pain was epigastric/lower sternal, 10/10, nonradiating. Associated with SOB, but not nausea, vomiting, or diaphoresis. Initial vitals: BP 125/61   P 114   R 21   T 98.4   95% on RA   FS 377   Initial EKG showing afib with RVR with 2mm ST elevations in III and aVF and possible small ST depressions in I, avL. Given diltiazem 20mg IVP with conversion to sinus rhythm, but not resolution of pain. Repeat EKG showing continued ST elevation in the inferior leads, so MEHEART (STEMI code) was activated by ED. Pt given…
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SEATTLE II

Cardiology, CCU Rotation, Respiratory, Why We Do What We Do
Stephanie Haimowitz, PGY3   AS is a 43 yo F, on OCPs for menorrhagia, h/o recent left ACL tear and as a result decreased ambulation x3 weeks, p/w SOB, worse on exertion x2 weeks but acutely worsening on the day of presentation. On the day of presentation, the patient complained of an episode of acutely worsening dyspnea, now occurring at rest and associated with lightheadedness, chest pressure, and diaphoresis. On Exam, the patient was mildly tachycardic with an O2 sat of 98% on RA at rest. She appeared to be breathing comfortably, although at times noted to take shallow breaths, and the remainder of her exam was unremarkable. Labs were notable for an elevated troponin of 0.302. EKG showed sinus tach with a ventricular rate of 106 and an incomplete…
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Goodbye MONA? Oxygen in AMI

Cardiology, CCU Rotation, Journal Club, Why We Do What We Do
Goodbye MONA? [caption id="" align="alignnone" width="291"] From: Best Mona Lisa Parodies @ http://beforeitsnews.com/fun-news/2011/09/the-best-mona-lisa-parodies-1167194.html[/caption] Dr. Mayuri Patel PGY3 CC: Chest pain and Shortness of breath HPI: 72F w/ PMHx of Rheumatic fever (s/p AVR repair 9 years prior), pHTN, hFrEF (EF 30%), HLD, DVT (on coumadin) s/p IVC filter BIBEMS for progressive DOE over 1 month. Prior to arrival to ED, pt developed substernal chest pain radiating to jaw associated with diaphoresis and nausea. EMS placed patient on NRB. Triage VS afebrile BP 129/85 HR 74 RR 24 02 96%RA General: awake, mild distress, oriented to person, place and time CVS: RRR Pulm: CTA – b/l Abd: +bs, soft, nt/nd Ext: 2+ pulses, no cyanosis or edema EKG – Sinus rhythm, HR 74, STE II, III, aVF with reciprocal changes Troponin…
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July 2014 CCU Rotation

CCU Rotation
  Anthony Clarke, PGY3 July 2014 HPI A 38 year-old obese male  active smoker with history of Asthma, Hypertension, Hyperlipidemia, poorly controlled Type II Diabetes, Acute Tubular Necrosis, and Pancreatitis who  presented with non-radiating, sub-sternal crushing chest pain for 1 hour. The patient described his pain as pressure as if someone was sitting on his chest. He also endorsed nausea,diaphoresis and complained of dyspnea on exertion for about 6 hours prior to his chest pain. On review of systems he denied syncope, drug or alcohol use. He was given sublingual nitroglycerin by EMS which did not alleviate his  chest pain. Exam In ED patient was seen to be  pale, clammy, appeared to be in moderate to severe distress. His vitals were 137/92, 82, 96.5, 20, 100% 2LNC.  His cardiac and…
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Is Bicarbonate ever Indicated in DKA? – Dr. E. Sosa

CCU Rotation
Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, elevated serum ketones, and metabolic acidosis. To explain briefly, this disorder results from dysfunctional glucose metabolism in the context of insulin underproduction and/or insensitivity. Unable to utilize glucose, cells begin to consume fatty acids via anaerobic metabolism, leading to the buildup of acidic ketone bodies and other electrolyte abnormalities. Some common precipitants of this acutely life-threatening condition include infection and noncompliance with insulin therapy in known diabetics. DKA is often how new-onset diabetics initially present, but it can also be found in patients with acute pancreatitis, MI, and CVA. Nevertheless, the complexity of metabolic derangements that come with DKA can be formidable to manage, regardless of the precipitating insult.1 Resuscitation of a DKA patient involves aggressive fluid replacement and insulin administration, all while…
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