Clinical Practice Points
This meta-analysis of recent, high-quality, multicenter trials examines whether femoral
or radial access site affects bleeding and mortality outcomes in patients with acute
coronary syndromes undergoing invasive management. The study found that radial access
reduced mortality, major adverse cardiac events, and major bleeding.
Use this study to:
- Start a teaching session with a multiple-choice question. We've provided one below.
- Review with your learners the potential adverse events that might occur during or
after a cardiac catheterization. To which might your learners be asked to respond?
Do they know what to do for each? Invite an interventional cardiologist to join the
- What are the potential advantages to catheterization via the femoral artery? What
are the potential advantages to using the radial artery?
- Ask why your learners think major bleeding is less common when catheterization is
performed via the radial artery.
- What do your learners think might account for the differences in adverse events found
in this study? Use the accompanying editorial to help prepare.
- Teach at the bedside! Take your team to the cardiac catheterization laboratory of
your hospital, and arrange for someone involved in the immediate postinterventional
care of patients to show your team the steps taken to prevent and monitor patients
for major complications after catheterization.
Preexposure prophylaxis (PrEP) for HIV prevention is recommended for those at high
risk for HIV infection. This multimedia feature includes a video interview with a
patient, a video of a Grand Rounds debate between 2 experts in HIV care, supplemental
slides, and the accompanying paper. It addresses the care of a patient for whom the
application of current clinical care recommendations is not clear-cut.
Use this feature to:
- Ask which patients are considered at high risk for HIV infection and for whom PrEP
- Review with your learners which patients are considered at high risk for HIV infection
and for whom PrEP is recommended. What factors affect the sexual transmissibility
of HIV? Use the table in the paper. Ask your learners if they know how to prescribe
PrEP. How effective is it? What are its side effects and costs? These are discussed
in the Grand Rounds presentation and paper.
- Review the questions in Table 3, and choose several for discussion with your learners.
For example, do your learners think that incorporating PrEP into clinical practice
sends a “mixed message” (by disinhibiting some patients, increasing
transmission risk, and/or increasing the risk for other sexually transmitted infections)?
- Watch the Grand Rounds discussion, or assign 2 of your learners to summarize the key
arguments in favor of and those against recommending PrEP for Mr. X. What do your
learners recommend now?
- Use the included multiple-choice questions to help conduct a teaching session. Be
sure to sign in and enter your answers to earn CME credit for yourself!
A 75-year-old woman is evaluated in the hospital 4 hours after onset of chest pain
with findings of an ST-elevation myocardial infarction. She was taken emergently to
the catheterization laboratory and underwent emergency percutaneous coronary intervention
for a totally occluded vessel. Her post-intervention ventriculogram demonstrated a
left ventricular ejection fraction of 30%. One hour after the procedure, she developed
an acute arrhythmia. Medications are aspirin, metoprolol, atorvastatin, and clopidogrel.
On physical examination, the patient is afebrile, blood pressure is 100/60 mm Hg,
pulse rate is 92/min, and respiration rate is 12/min. BMI is 25. Neck examination
demonstrates cannon a waves. Cardiac examination demonstrates regular rhythm with a variable S1. Lungs are clear to auscultation.
Electrocardiogram is shown.
Which of the following is the most appropriate management?
C. Implantable cardioverter-defibrillator
E. No intervention
E. No intervention
Accelerated idioventricular rhythm is a common complication following coronary reperfusion
and does not require intervention when it occurs within 24 hours of reperfusion.
Educational Objective: Manage an accelerated idioventricular rhythm following myocardial
This patient requires no further intervention at this time. She developed a wide complex
rhythm shortly after percutaneous coronary intervention and reperfusion of her infarct-related
artery. The electrocardiogram (ECG) shows a regular wide complex rhythm at 92/min
with no clearly discernible atrial activity, findings consistent with accelerated
idioventricular rhythm (AIVR). AIVR is postulated to result from abnormal automaticity
in the subendocardial Purkinje fibers. It is observed in up to 15% of patients who
undergo reperfusion of an infarct-related artery. The rate is almost always less than
120/min and usually less than 100/min. Most studies have shown that it is a benign
rhythm when it occurs within 24 hours of reperfusion. This patient is tolerating the
rhythm well and is already on a β-blocker for post–myocardial infarction
care; therefore, no intervention is required.
Neither amiodarone nor lidocaine is indicated because AIVR is a benign ventricular
arrhythmia and usually does not recur. Studies of prophylactic lidocaine after acute
coronary syndromes have demonstrated potential harm, and amiodarone has been associated
with decreased survival after myocardial infarction.
Cardioversion is not indicated because AIVR is a transient rhythm and, in this patient,
it is well-tolerated.
AIVR usually indicates successful (or at least partial) reperfusion and is considered
a reversible arrhythmia. Implantable cardioverter-defibrillator (ICD) placement is
not indicated at this time given the patient's recent revascularization and nature
of the arrhythmia. If the left ventricular ejection fraction remains low despite medical
therapy, ICD placement might be indicated in the future.
Bonnemeier H, Ortak J, Wiegand UK, et al. Accelerated idioventricular rhythm in the
post-thrombolytic era: incidence, prognostic implications, and modulating mechanisms
after direct percutaneous coronary intervention. Ann Noninvasive Electrocardiol. 2005
Apr;10(2):179-87. PMID: 15842430
This question was derived from MKSAP® 17, the latest edition of the Medical Knowledge Self-Assessment Program.