Download ESC Congress 2012 - ClinicalKey symposium

Improving Clinical Decisions and Processes:
How to get better answers faster to challenging
questions in cardiology
ESC 2012, Satellite Symposium – 26 August 2012
Sponsored by Elsevier ClinicalKey
Agenda
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13:00
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Prof. Dr. Stephan Achenbach
Universitätsklinikum Erlangen Medizinische Klinik 2, DE
13:10
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Introduction.
Getting better answers faster in a
challenging cardiology case
Dr Michael H Crawford
Professor of Medicine, UCSF
Jon Hickey
e-Clinical Reference & Clinical Decision Support, Elsevier
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13:30
Q&A
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13.45
Symposium Close
Sponsored by Elsevier ClinicalKey
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Growth of Medical Knowledge
http://www.healthcare.uiowa.edu/2020/index.html
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Growth of Medical Knowledge
1 million articles per
year expected in 2012
Medical specialists
would need 21 hours of
reading a day to stay
current
Gillam M et al
http://research.microsoft.com/en-us/collaboration/fourthparadigm/4th_paradigm_book_part2_gillam.pdf
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Where to turn for Knowledge?
60 pages
120/270 references ≤ 3 years old
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How often do Doctors Look for Information?
In an average week,
information sources
are consulted up to
five times to support
diagnosis and
treatment
Hospital Physician Information Survey [UK: 100 Clinicians]
Conducted by Opinion Health on behalf of ClinicalKey
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Where do they turn?
Journals
Google
Clinical Search
Engine
Textbooks
Peers
Most used
information source
(Q3a)
Rating mean
score for each
source (Q3b-d)
Hospital Physician Information Survey [UK: 100 Clinicians]
Conducted by Opinion Health on behalf of ClinicalKey
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What are the Frustrations?
Hospital Physician Information Survey [UK: 100 Clinicians]
Conducted by Opinion Health on behalf of ClinicalKey
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The Challenge
How can information be
Current
Comprehensive
Concise
Reliable
and readily accessible?
Agenda

13:00 Introduction.


Prof. Dr. Stephan Achenbach
Universitätsklinikum Erlangen Medizinische Klinik 2, DE
13:10 Getting better answers faster in a challenging
cardiology case


Dr Michael H Crawford
Professor of Medicine, UCSF
Jon Hickey
e-Clinical Reference & Clinical Decision Support, Elsevier

13:30 Q&A

13.45 Symposium Close
Sponsored by Elsevier ClinicalKey
10
Users & Workflows in Cardiology
Sponsored by Elsevier ClinicalKey
Clinical Case (1/3)
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72 year old woman presents with worsening fatigue, ankle
edema, abdominal bloating & dyspepsia for 6 months.
Fatigue started 3 years ago when echocardiogram showed
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normal biventricular size & function
mild mitral regurgitation
mild to moderate tricuspid regurgitation
mildly enlarged atria
Doppler findings consistent with impaired left ventricular
relaxation and elevated filling pressures.
Treated with a thiazide diuretic.
No other significant past history.
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Clinical Case (2/3)
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Physical examination
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blood pressure of 134/70, heart rate of 89 irregular
clear lung fields
jugular venous pressure of 12cm with a prominent v wave.
apical impulse not palpable
slight right ventricular tap along left sternal border, first &
second heart sounds were normal
fourth heart sound & grade 2/6 pansystolic mumur at lower
left sternal border that increased in intensity with inspiration
Liver edge palpable & tender
Abdomen distended
2+ lower leg edema.
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Clinical Case (3/3)
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Initial laboratory work
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ECG
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atrial fibrillation with average rate of 86, but no other abnormalities
Echocardiogram
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mildly elevated liver function tests, BNP of 279, INR of 1.4,
creatinine of 1.1
normal left ventricular size and function
mildly dilated right ventricle with normal function
marked bilateral atrial enlargement
mild mitral & severe tricuspid regurgitation, with normal valve anatomy
Diastolic function
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could not be determined due to atrial fibrillation
estimated PASP is 52 mmHg and LVOT VTI is low
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Tricuspid regurgitation
Source: Indian J Endocrinol Metab. 2011 Apr-Jun; 15(2): 137–139,
Mohammad Hayat Bhat et al.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3125005/
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Treatment plan - questions?
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Treatment with loop diuretic
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Treament with beta blocker
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Improved edema & abdominal distention, but fatigued remained
especially on exertion, and low appetite.
Increased fatigued so stopped
Cardioversion rejected as therapeutic option due to atrial sizes
Questions:
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Medical therapy for significant tricuspid regurgitation?
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Indications for surgery in significant tricuspid regurgitation,
possibly due to annular dilatation and right atrial dilatation?
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If surgery contemplated - repair, annuloplasty, biologic valve,
or mechanical valve?
Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Elsevier ClinicalKey: 2012 Editorial Advisory Board
David Goldmann, M.D., FACP, Board Chair
Michael H. Crawford, M.D. (Cardiovascular Disease).
Joseph Ming Wah Li, M.D. (Hospital Medicine)
Jay S. Duker, M.D. (Ophthalmology)
Hugh C. Hemmings Jr., M.D., PhD (Anesthesiology, Pharmacology)
Frank H. Miller, M.D. (Radiology)
Thomas Moore, M.D. (Obstetrics & Gynecology/Reproductive Medicine)
M. Blair Marshall, M.D. (Thoracic Surgery)
Bonita Stanton, M.D. (Pediatrics)
Denne Thomas-Patterson, M.D. (Family Medicine)
Stephen R. Thompson, M.D., MEd, FRCSC (Orthopedic Surgery/Sports Medicine)
Todd W. Thomsen, M.D. (Emergency Medicine)
Leonard S. Lilly, M.D.Sponsored
(Cardiovascular
by ElsevierDisease)
ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Tricuspid Annular Dilation (A) Normal tricuspid valve. (B) Asymmetric dilation and deformation of the tricuspid annulus leading to tricuspid regurgitation. A = anterio
posterior leaflet; S = septal leaflet.
The Growing Clinical Importance of Secondary Tricuspid Regurgitation
Taramasso, Maurizio, MD, JACC (Journal of the American College of Cardiology), Volume 59, Issue 8, 703-710
Copyright © 2012 American College of Cardiology Foundation
Kay Repair Technique (A) Tricuspid valve bicuspidization is accomplished by plicating the annulus along the posterior leaflet. (B) The sutures are tied, obliterating
leaflet, creating a bicuspid valve. Figure illustration by Craig Skaggs.
Figure illustration by Craig Skaggs.
The Growing Clinical Importance of Secondary Tricuspid Regurgitation
Taramasso, Maurizio, MD, JACC (Journal of the American College of Cardiology), Volume 59, Issue 8, 703-710
Copyright © 2012 American College of Cardiology Foundation
Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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61 pts isolated severe TR had surgery
93% had previous left valve surgery
Operative mortality 10%
Long term 3 died and 6 were rehospitalized for
cardiovascular problems
Over 32 months follow up 75% event free survival
61% improved their functional class
Predictors of good outcome: RV area <20cm2 and Hgb >11
Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Sponsored by Elsevier ClinicalKey
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Small, retrospective, observational study of the results of
TV annuloplasty for functional TR
Assumption: Annular dilatation is the major cause of
function TR
Predictors of residual TR (mod-severe) at one year:
Preop LVEF <37% and Tethering of the TV
Predictors of hospital discharge residual TR: EF and
preop TR severity
Severity of TR during follow-up related to RV pressure
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Clinical Case Conclusions
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In support of surgery:
Symptomatic despite medical therapy
 Severe tricuspid regurgitation
 Mild pulmonary hypertension
 Mildly dilated RV with normal function
 Normal TV anatomy
 Normal LV systolic function
 No previous cardiac surgery
 No significant co-morbidities
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Sponsored by Elsevier ClinicalKey
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Agenda

13:00 Introduction.


Prof. Dr. Stephan Achenbach
Universitätsklinikum Erlangen Medizinische Klinik 2, DE
13:10 Getting better answers faster in a challenging
cardiology case


Dr Michael H Crawford
Professor of Medicine, UCSF
Jon Hickey
e-Clinical Reference & Clinical Decision Support, Elsevier

13:30 Q&A

13.45 Symposium Close
Sponsored by Elsevier ClinicalKey
39
Improving Clinical Decisions and Processes:
How to get better answers faster to challenging
questions in cardiology
ESC 2012, Satellite Symposium – 26 August 2012
Sponsored by Elsevier ClinicalKey