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December 15, 2015 Issue


Clinical Practice Points

Medical Knowledge

Radial Versus Femoral Access in Invasively Managed Patients With Acute Coronary Syndrome. A Systematic Review and Meta-analysis

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 discussion.
  • 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.


Medical Knowledge
Patient Care
Interpersonal / Communication Skills

Beyond the Guidelines: Preexposure Prophylaxis for HIV Prevention

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 is recommended.
  • 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!


Video Learning

Medical Knowledge
High Value Care
Consult Guys logo

The Consult Guys: Excluding the Diagnosis of Pulmonary Embolism: Is There a Magic Ball?

In this episode of the consultative medicine video series, Howard and Geno take on the perplexing issue of how sure one can be when excluding the diagnosis of pulmonary embolism.

Use this feature to:

  • Watch the short video, and answer the brief multiple-choice questions with your learners. Be sure to sign in and enter your answers to earn CME credit.
  • Ask your learners to name all the components of the Pulmonary Embolism Rule-Out Criteria.
  • Ask them to explain in what situation the PERC is useful. When is it not useful?


Practicing Medicine and Our Health Care System

Professionalism
Systems-based Practice

Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices: A Policy Position Paper From the American College of Physicians

This ACP position paper discusses the effect of direct patient contracting practices—often called cash-only, retainer, boutique, concierge, or direct primary care or specialty care practices—on access, cost, and quality; discusses principles that should apply to all practice types; and makes recommendations to mitigate any adverse effect on underserved patients.

Use this paper to:

  • Ask your learners to define “concierge” medical practice. Review the practices discussed in this position paper that involve a direct contract between the medical practice and the patient.
  • Ask your learners to list the potential advantages and disadvantages of a “concierge” practice for physicians. What are the potential advantages and disadvantages for patients?
  • Do your learners think direct patient contracting practices are more likely to increase or decrease costs?
  • Do your learners agree with the recommendations made by the ACP? Are there additional recommendations they would make?
  • What do your learners think about direct patient contracting? Do they think they will be interested in incorporating direct patient contracting into their practices?


Humanism and Professionalism

Professionalism

On Being a Doctor: The Smile

In her essay, Dr. Freeman describes her initial irritation at the imposition medical practice posed on her time with her child, and what changed her feelings.

Use this essay to:

  • Listen to an audio recording by Dr. Michael LaCombe.
  • Ask your learners what situations cause them to resent their lives as physicians. Do they ever resent their patients? Their colleagues?
  • How do your learners handle these emotions?


mksap17

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.

afed201512150_mksap1.jpg

Which of the following is the most appropriate management?

A. Amiodarone
B. Cardioversion
C. Implantable cardioverter-defibrillator
D. Lidocaine
E. No intervention

Correct Answer
E. No intervention

Key Point
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
Educational Objective: Manage an accelerated idioventricular rhythm following myocardial infarction.

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.

Bibliography
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.



From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University.

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