Article

Electrocardiogram changes and prognosis of takotsubo cardiomyopathy

724 Correspondence

coronary sinus due to APE-related dilation of the pulmonary artery. Coronary angiography can help diagnose these comorbidities. All the 2 cases with STE in the inferior leads resulting from paradoxical right coronary artery [4] or left circumflex coronary artery [5] embo- lism showed simultaneous STE in leads V5 to V6. This is not the typ- ical inferior STE pattern resulting from isolated APE [1,6]. The typical inferior STE pattern resulting from isolated APE is with or without STE in the Right precordial leads of V1 or V1 to V2/V3/V4. transmural ischemia in RV-related APE, due to hypotension, hypoxemia, RV stretches, and catecholamine surge [6-8], can cause STE in the right precordial leads with or without STE in the inferior leads because in- ferior leads (especially in leads III and/or aVF) can record the electri- cal activity of the inferior wall of the RV and lead V1 faces the anterior wall of the RV and, in cases of RV dilation, lead V2 and sometimes lead V3 face the anterior wall of the RV. However, the ST-segment in the leads V5 to V6 is usually depressed due to the subendocardial ischemic in the Left ventricle [1,6,9]. Conversely, inferior STEMI can cause APE due to embolism from RV thrombus from a case report in 1989 [10]. Acute pulmonary embolism can cause both STE in the inferior leads and elevated markers of Myocardial necrosis and thus masquerading as STEMI. On the other hand, APE can also accompanied by right-sided cardiac thrombus [11]. Therefore, it will be very difficult to gain a conclusion that inferior STEMI can cause APE due to embolism from RV thrombus. Finally, the author(s) [3] precisely commented that aortic dissection should be included in the differential diagnosis in electrocardiogram changes and prognosis “>patients suspected with APE or inferior STEMI because ascending aortic hematoma associated with aortic dissection can compress the right coronary artery [12] or Right pulmonary artery [13].

Based on our previous studies [1,6,8,9,14], we summarized the

typical ischemic electrocardiographic patterns associated with APE without concomitant paradoxical Coronary embolism or mechanical obstruction of coronary artery: (i) STE in Lead aVR with concomitant ST-segment depression in leads V4/V5 to V6 (LV subendocardial is- chemic pattern), (ii) STE in at least 2 of the inferior leads or in leads of V1 to V3/V4 (RV transmural ischemic pattern), (iii) STE in leads III and/or V1/V2 with concomitant ST-segment depression in leads V4/V5 to V6 (LV subendocardial plus RV transmural ischemic pattern). The 3 typical ischemic patterns accompanied by RV strain pattern are highly suspicious of APE.

Zhong-Qun Zhan, MD? Chong-Quan Wang, MD

Department of Cardiology, Shiyan Taihe Hospital, Hubei University of

Medicine, Shiyan City, Hubei Province, China

?Corresponding author at: Department of Cardiology Shiyan Taihe Hospital, Hubei University of Medicine, Shiyan City

Hubei Province, China E-mail addresses: [email protected] (Z.Q. Zhan) [email protected] (C.Q. Wang)

Bo Yang, MD

Department of Cardiology, Renmin Hospital of Wuhan University

Wuhan, China E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2015.02.015

References

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    Electrocardiogram changes and prognosis of takotsubo cardiomyopathy?,??,?

    To the Editor,

    We read the article “Stimulant-related Takotsubo cardiomyopathy” by Butterfield et al [1] in the previous issue of the American Journal of Emergency Medicine with great interest. The authors described a very interesting case of takotsubo cardiomyopathy (TC) associated with cocaine abuse. The patient did have a remarkable electrocardio- gram (ECG) changes and was successfully treated with conservative management.

    We would like to emphasize 2 important issues related to this case presentation. First, although most patients with TC have ECG changes at presentation, as seen in this case, up to 30% of patients could have a completely normal ECG [2,3]. Thus, a normal ECG does not always rule out the diagnosis of TC. Second, TC is not always a Benign condition, and sometimes, an aggressive intervention is required because a recent systematic review had demonstrated an in-hospital mortality of up to 3% [2].

    Patompong Ungprasert, MD

    Division of Rheumatology, Mayo Clinic, Rochester, MN

    Corresponding author

    E-mail address: [email protected]

    [email protected]

    ? Funding: None.

    ?? Conflict of interest statement for all authors: We do not have any financial or nonfi-

    nancial potential conflicts of interest.

    ? Author contributions: All authors had access to the data and a role in writing the article.

    Correspondence 725

    Narat Srivali, MD

    Division of Pulmonology and Critical Care Medicine

    Mayo Clinic, Rochester, MN

    http://dx.doi.org/10.1016/j.ajem.2015.02.021

    References

    Butterfield M, Riguzzi C, Frenkel O, Nagdev A. Stimulant-related Takotsubo cardiomy- opathy. Am J Emerg Med 2014 [Epub ahead of print].

  15. Ahmed S, Ungprasert P, Ratanapo S, Hussain T, Riesenfeld EP. Clinical characteristics of takotsubo cardiomyopathy in North America. N Am J Med Sci 2013;5(2):77-81.
  16. Pelliccia F, Parodi G, Greco C, Antoniucci D, Brenner R, Bossone E, et al. Comorbidities frequency in Takotsubo syndrome: an international collaborative systematic review including 1,109 patients. Am J Med 2015 [Epub ahead of print].

    Nonsteroidal anti-inflammatory drugs and venous thromboembolism?,??,?

    To the Editor,

    We read the article entitled “A rare cause of pulmonary embolism: panax” by Yigit and Cevik [1] with great interest. We would like to thank the authors for their excellent case presentation. This case emphasizes the importance of medication history as the crucial clue to the accurate diagnosis. We would also like to underscore the impor- tance of the history of over-the-counter medications use because non- steroidal anti-inflammatory drugs are capable of increasing the venous thromboembolism risk. This increased risk has been well illus- trated in a recent meta-analysis with the risk ratio of 1.8 among the users [2]. With the wide-spread use of nonsteroidal anti- inflammatory drugs [3], this history would be of importance for the physicians and patients to minimize the chance of recurrence of this potentially fatal illness.

    Patompong Ungprasert, MD

    Division of rheumatology, Mayo Clinic, Rochester, MN, USA

    Narat Srivali, MD

    Division of pulmonology and critical care medicine

    Mayo Clinic, Rochester, MN, USA

    *Corresponding author

    E-mail addresses: [email protected]

    [email protected]

    http://dx.doi.org/10.1016/j.ajem.2015.02.028

    References

    Yigit M, Cevik E. A rare cause of pulmonary embolism: panax. Am J Emerg Med 2014 [Epub ahead of print].

  17. Ungprasert P, Srivali N, Wijarnpreecha K, Charoenpong P, Knight EL. Non-steroidal anti-inflammatory drugs and risk of venous thromboembolism: a systematic review and meta-analysis. Rheumatology (Oxford) 2014 [Epub ahead of print].
  18. Ungprasert P, Kittanamongkolchai W, Price C, et al. What Is The “Safest” Non- Steroidal Anti-Inflammatory Drugs? Am Med J 2012;3(2):115-23.

    ? Funding: None.

    ?? Conflict of interest statement for all authors: We do not have any financial or nonfi-

    nancial potential conflicts of interest.

    ? Author contributions: All authors had access to the data and a role in writing the article.

    Knowledge, attitudes, and practices regarding infection prevention among emergency medical

    services providers?,??,?

    To the Editor,

    Infection prevention isa significant challenge in prehospital emergency care. Hand hygiene [1-3], adherence to standard and transmission-based precautions [4], and environmental disinfection [1] by emergency medical services (EMS) providers is variable and often suboptimal. Ambulances can become contaminated during patient care with multidrug-resistant organisms (MDRO) [5-7], increasing the potential for transmission. Little is known about the knowledge, attitudes, and practices of EMS providers in relation to infection prevention and MDRO transmission.

    We designed a questionnaire to assess EMS provider knowledge of and self-reported adherence to infection prevention practices. Familiarity with MDROs and how they are transmitted in health care settings was determined. The 22-item questionnaire was electronically distributed to a random sample of EMS providers certified through the National Registry of Emergency Medical Technicians between November 2013 and February 2014. Descriptive statistics were calculated using STATA/IC 12 (StataCorp LP, College Station, TX). Differences in MDRO Knowledge based on level of training were examined using the ?2 test.

    Five hundred sixteen (9.7%) EMS providers completed the question-

    naire. Mean age of respondents was 40 years. Thirty-five percent had less than 5 years of experience as an EMS provider, 22% had 5 to 10 years, and 43% reported 10 years or more. More than half (55%) were basic life support (BLS) providers, predominantly Emergency Medical Technician-Basics. Forty-five percent were Advanced life support providers, of which paramedics represented more than 75%.

    Eighty-five percent reported almost always wearing gloves during patient care. Although 95.3% felt that hand hygiene was necessary regardless of glove use, only 16.1% regularly disinfected their hands before glove use (>=80% of the time); 68.9% did so afterwards (Table). Twenty-nine percent hardly ever disinfected their hands before glove use. Respondents cited lack of time (40.6%), interference with patient care (35.5%), and perceived low risk of exposure to blood or other body fluids (25.6%) as common reasons for hand hygiene nonadherence. Although 85.9% routinely disinfected their medical equipment and stretcher after each patient encounter, less than 60% disinfected the ambulance compartment during a shift, even after visible environmen- tal contamination. Although 80.3% of respondents’ organizations had a written infection prevention policy, only 60.1% had a designated infec- tion prevention officer. Most respondents reported receiving 1 to 5 hours of infection prevention training annually (62.0%).

    Although most BLS and ALS providers were familiar with methicillin- resistant Staphylococcus aureus (93.2% vs 99.4%; P = .002), fewer BLS than ALS providers had heard of vancomycin-resistant Enterococcus (44.4%

    ? This article was presented as a poster abstract at 2014 IDweek, Philadelphia, PA (October 9, 2014).

    ?? Conflicts of interest: J.M. has served as a consultant for Gilead Switzerland and was on

    an advisory board for Astellas Inc, Switzerland. None of the other authors have a conflict of interest to declare.

    ? Funding and support: S.L. is the recipient of a KM1 Comparative Effectiveness Research

    Career Development Award (KM1CA156708-01) and received support through the Clinical and Translational Science Award (CTSA) program (UL1RR024992) of the National Center for Advancing Translational Sciences (NCATS) as well as the Barnes-Jewish Patient Safety and Quality Career Development Program, which is funded by the Foundation for Barnes- Jewish Hospital. J.M. was supported by the National Institutes of Health CTSA/NCATS (UL1RR024992) and was a recipient of a KL2 Career Development Grant (KL2RR024994).

    J.M. received support from the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Career Development Award through the NIH NCATS (5K12HD001459- 13). He is also the section leader for a subproject of the Centers for Disease Control and Prevention, Prevention Epicenters Program grant (U54 CK000162; PI Fraser). In addition,

    J.M. was funded by the Barnes-Jewish Hospital Patient Safety and Quality Career Develop- ment Program and by a research grant from the Foundation for Barnes-Jewish Hospital and Washington University’s Institute for Clinical and Translational Science.

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