Posted by James
Acute myocardial infarction with multivessel coronary artery disease was the common feature in our three patients. During the course of their myocardial infarctions all three developed atrial tachyarrhythmias that required electrical cardioversion. This was followed by severe, prolonged bradycardia that required ventricular pacing. There was no clinical evidence of intrinsic sinus node dysfunction prior to their hospitalization, and one of the patients (case 2) has not demonstrated any evidence of sinus node dysfunction over a one-year follow-up period.
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Posted by James
Case 1
A 74-year-old man was admitted to the hospital with unstable rest angina. Forty-eight hours after admission he developed severe prolonged chest pain of 3 hours’ duration. His electrocardiogram revealed sinus rhythm and changes of anterior and inferior myocardial infarctions of indeterminate age and a possible acute lateral wall infarction. Creatine kinase (CK) peak was 2,002 IU/L, with a peak CK MB of 15.2 percent. He exhibited recurrent rest angina and subsequently developed hypotension requiring insertion of an intra-aortic balloon pump. His chest pain resolved following insertion of the balloon pump, but he required vasopressors to maintain an adequate blood pressure, and later he developed atrial flutter with a ventricular response of 150/min and was hypotensive in spite of pressor infusions. In view of his hemodynamic instability, urgent electrical cardioversion was performed. An initial countershock of 50 joules was unsuccessful, and a second 50-joule countershock was repeated. This resulted in severe sinus bradycardia (less than 30 beats/min) and worsening of hypotension. Cardiopulmonary resus- citative efforts (including IV atropine and IV epinephrine) failed and the patient died.
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Posted by James
Symptomatic bradycardia is an uncommon complication following electrical cardioversion for an atrial tachyarrhythmia. In patients with acute myocardial infarction, atrial tachyarrhythmia associated with hemodynamic compromise or worsening of ischemia requires electrical cardioversion. Read the rest of this entry »
Posted by James
In regard to our second study question, we found no significant differences in the life-sustaining treatment preferences, including preferences about duration of treatments expressed by ICU patients at the time of transfer from the ICU compared to those expressed by the same patients one month later when no longer in the ICU nor under the stress of an acute illness. These results suggest that patient preferences regarding life-sustaining treatments are stable over one month despite changes in health and mood. Two
studies of cancer patients’ preferences obtained similar results. One study found that cancer patient preferences for treatment did not change significantly when measured before and then six months following treatment despite significant treatment toxicity. Another study of patients with laryngeal cancer showed stability of values regarding voice expressed before and after treatment despite changes in clinical state. In contrast, women’s preferences about anesthesia during childbirth changed significantly during labor when compared to those expressed before and after labor. Our results may be more consistent with those found in the studies of cancer patient preferences because of similarities in the two populations. Our study patients, like the cancer patients, are older, have more chronic disease and are confronting choices about life- sustaining treatments and not about treatment of a symptom during a limited situation such as childbirth.
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Posted by James
In this study we explored two questions: (1) what are the life-sustaining treatment preferences of critically ill ICU patients; and (2) are these preferences stable over a one-month period. In regard to the first question, ICU patients expressed a diversity of life-sustaining treatment preferences. Preferences regarding one treatment did not generalize to other treatments. Furthermore, preferences regarding a particular life-sustaining treatment often changed under the markedly different clinical conditions presented in the three scenarios. These findings suggest that patient preferences are difficult to predict. We already know that patient preferences do not appear to be strongly correlated with demographic characteristics or health status measures. Thus, it is not surprising that physicians are inaccurate in predicting patient preferences.
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Posted by James
Fifty-three percent of the ICU patients had previously discussed their preferences about life-prolonging treatments with another person. However, only 10 percent of patients reported communicating their views to a physician. Forty-three percent of married patients had talked with their spouse about their preferences for life-sustaining therapies.
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Posted by James
The age of our study participants was 64 ± 9 years. Most patients were white (90 percent), cognitively intact (90 percent by the Short Pbrtable Mental Status questionnaire criteria), and had at least a high school education (59 percent). Other patient characteristics are presented in Table 1.
Percentages of patients favoring each life-sustaining treatment in the three scenarios are shown in Table 2. Most patients desired resuscitation in the current health situation and hospitalization for the treatment of pneumonia in the stroke and dementia scenarios. Fewer patients wanted the other treatments. Larger percentages of patients favored therapies in the current health situation than in the other scenarios.
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