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08/10/2011 - HHS and cardiac ischemia

posted Sep 20, 2011, 8:01 AM by Chief Resident   [ updated Sep 20, 2011, 5:32 PM by Purnema Madahar ]
Another weekend is lying ahead of us, so let me reiterate a few points:

1. Check the coverage sheets posted in the NW5 conference room and either make corrections on the sheet or let me know if you spot an error.
2. Be very detailed in your signout, especially if your notes will be written by dayfloat; I've got feedback from both sides: dayfloats thought that signout wasn't clear enough and teams found that dayfloats weren't thorough enough. Think through each weekend day and ask yourself what should be done for your patients.
3. Residents, sign out sick patients to your sister team's resident. 
4. Sign out potential weekend discharges to SW at 3 pm.

Let's try to pay a bit more attention to timeliness: both for Chief of Service yesterday as for resident report this morning, folks were on the late side. Especially for case presentations, it doesn't work so well if people come late.

During intake, Camile Gooden presented a patient who was admitted in a severe hyperosmolar hyperglycemic state, who went on to have an NSTEMI. It proved rather difficult to find literature that describes this exact phenomenon, but you will find two case reports attached that posit that HHS is a pro-thrombotic state mediated by hyperviscosity and hypercoagulation. 

The American Heart Association acknowledges our incomplete understanding of the above problem in its Scientific Statement on Hyperglycemia and the Acute Coronary Syndrome. It's an excellent, concise read that lays out some important clinical dilemmas:
1. There is a clear relationship between admission glucose levels and mortality in ACS.
2. But, the AHA asks: is hyperglycemia a marker of high risk or a mediator of adverse outcomes?
3. Although many pathophysiologically plausible theories exist, data on the association of hyperglycemia and outcomes in ACS are largely observational.
4. Three out of 4 randomized trials comparing different strategies of glucose control in ACS failed to show a difference in mortality.