An eldely man with a hx of hypothyroidism, recent L TKR and a hx of DVT 1 year prior who was called to come to the ED for a heart rate in the 130s found to be in new afib.
Key Learning Points
*Don’t treat subclinical hypothyroidism unless T4 is > 10 or thyroid antibody is +; the reason for treating subclinical hypothyroidism is risk of progressing to an overt hypothyroid state
*IV metop vs. PO Metop
-Per Kaiser Guidelines – oral beta blocker therapy is preferred over IV therapy in the setting of acute MI; oral administration should be initiated within the first 24 hours for MI patients who do not have any of the following (a) heart failure, (b) low output state, (c) increased risk for cardiogenic shock, or (d) other relative contraindications (PR > 240 msec, 2nd or 3rd degree heart block, active asthma or reactive airway disease). Early aggressive IV beta blockade can pose a net hazard in hemodynamically unstable patients.
*Number to transfuse in setting of ACS?
-The optimal transfusion threshold in the setting of ACS remains unresolved. In general transfuse when the Hgb is < 8 g/dL and consider transfusion when the Hgb is between 8 and 10 g/dL. Pilot trial of 110 patients with ACS demonstrated that a liberal transfusion strategy to raise the Hgb >/= 10 was associated with greater survival at 30 days
An elderly woman with a pmh of moderate AS and a R TKA 5 years prior who initially presented to her PCP with R knee pain. She was initially treated with a steroid injection as well as a course of PO prednisone. Several weeks later she continued to have knee pain and was seen by ortho – arthrocentesis at that time revealed a WBC of 25K and culture grew out Step Milleri – she was started on antibiotics. Plans were made for a 2 step knee replacement. During pre-op workup, she was noted to be in atrial fibrillation. She was subsequently sent home with an event monitor and was called back to the ED after it detected 3rd degree heart block. Subsequent ECHO demonstrated perivalvular abscess involving the aortic valve. Unfortunately, she was deemed too high risk for surgery, and was sent home on hospice with plans for comfort care.
-Pay attention to surgical history – the presence of hardware in this patient’s knee increased her risk of septic arthritis
-TTE sensitivity for vegetation is 75% compared with sensitivity of TEE which is > 90%
-Heart block should raise suspicions for perivalvular abscess, specifically involving the aortic valve
Duke’s criteria for endocarditis:
Criteria for Diagnosis: 2 Major; 1 Major and 3 Minor; 0 Major and 5 Minor
1) + Blood Cx for typical infective endocarditis organisms (S. Viridans or Bovis; HACEK, S. Aureus) from 2 separate blood cultures or 2 positive cultures from samples drawn > 12 hrs apart
2) Echo with oscillating intracardiac mass or valve or supporting structures in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or abscess, or new partial dehiscence of prosthetic valve or new valvular regurgitation
1) Predisposing heart condition or IV drug use
2) Temp > 38
3) Vascular phenomena: arterial emboli, pulmonary infarcts, mycotic aneurysms, intracranial bleed, conjunctival hemorrhages, Janeway lesions
4) Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots; RF
5) Microbiological evidence: positive blood Cx but does not meet a major criterion as noted above or serological evidence of active infection with organism consistent with endocarditis (excluding coag neg staph, and other common contaminants)
6) Echo findings: consistent with endocarditis but do not meet a major criterion as noted above