Cardiology – ClinCaseQuest https://clincasequest.hospital Medical education in clinical cases Sat, 22 Jul 2023 08:36:50 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.14 https://clincasequest.hospital/wp-content/uploads/sites/7/2020/02/logo-ru-project-90x90.png Cardiology – ClinCaseQuest https://clincasequest.hospital 32 32 Baseline Cardiovascular Risk Assessment in Cancer Patients Scheduled to Receive Cardiotoxic Cancer Therapies (Anthracycline Chemotherapy) – Online Calculator https://clincasequest.hospital/hfa-icos-risk-assessment/ Mon, 03 Jul 2023 18:58:05 +0000 https://clincasequest.hospital/?p=35727 Baseline cardiovascular risk assessment in cancer patients scheduled to receive cardiotoxic cancer therapies (Anthracycline Chemotherapy) from the Cardio-Oncology Study Group of the Heart Failure Association…

Сообщение Baseline Cardiovascular Risk Assessment in Cancer Patients Scheduled to Receive Cardiotoxic Cancer Therapies (Anthracycline Chemotherapy) – Online Calculator появились сначала на ClinCaseQuest.

]]> Baseline cardiovascular risk assessment in cancer patients scheduled to receive cardiotoxic cancer therapies (Anthracycline Chemotherapy) from the Cardio-Oncology Study Group of the Heart Failure Association of the European Society of Cardiology in collaboration with the International Cardio-Oncology Society (HFA-ICOS).

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Previous cardiovascular disease

Cardiac biomarkers (where available)

Demographic and cardiovascular risk factors

Previous cardiotoxic cancer treatment

Lifestyle risk factors

BMI, body mass index; BNP, brain natriuretic peptide; CABG, coronary artery bypass graft; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro-brain natriuretic peptide; PCI, percutaneous coronary intervention
a Elevated above the upper limit of normal for local laboratory reference range.
b Systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg, or on treatment.
c Glycated haemoglobin >7.0% or >53 mmol/mol, or on treatment.
d Estimated glomerular filtration rate <60 mL/min/1.73 m2.

* Required


Risk factorsScoreLevel of
evidence
Previous cardiovascular disease
Heart failure or cardiomyopathyVery highB
Severe valvular heart diseaseHighC
Myocardial infraction or previous coronary revascularization (PCI or CABG)HighC
Stable anginaHighC
Baseline LVEF <50%HighB
Borderline LVEF 50-54%Medium2C
Cardiac biomarkers
(where available)
Elevated baseline troponinMedium1C
Elevated baseline BNP or NT-proBNPMedium1C
Demographic and cardiovascular risk factors
Age ≥80 yearsHighB
Age 65–79 yearsMedium2B
HypertensionMedium1B
Diabetes mellitusMedium1C
Chronic kidney diseaseMedium1C
Previous cardiotoxic cancer treatment
Previous anthracycline exposureHighB
Prior radiotherapy to left chest or mediastinumHighC
Previous non-anthracycline-based chemotherapyMedium1C
Lifestyle risk factors
Current smoker or significant smoking historyMedium1C
Obesity (BMI >30 kg/m2)Medium1C
BMI, body mass index; BNP, brain natriuretic peptide; CABG, coronary artery bypass graft; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro-brain natriuretic peptide; PCI, percutaneous coronary intervention
a Elevated above the upper limit of normal for local laboratory reference range.
b Systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg, or on treatment.
c Glycated haemoglobin >7.0% or >53 mmol/mol, or on treatment.
d Estimated glomerular filtration rate <60 mL/min/1.73 m2.


HFA-ICOS risk assessment

no risk factor OR one medium1 risk factorLow risk<2%
medium risk factors with a total of 2–4 pointsMedium risk2-9%
medium risk factors with a total of ≥5 points OR any high risk factorHigh risk10-19%
any very high risk factorVery high risk>20%


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]]> Charlson Comorbidity Index (CCI) Online Calculator https://clincasequest.hospital/charlson-comorbidity-index/ Wed, 10 May 2023 13:55:51 +0000 https://clincasequest.hospital/?p=35025 Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities. Variable Points Age   <50 years 0 50–59 years +1 60–69 years +2 70–79…

Сообщение Charlson Comorbidity Index (CCI) Online Calculator появились сначала на ClinCaseQuest.

]]> Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

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History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

Chronic cognitive deficit

Any history of treatment for ulcer disease or history of ulcer bleeding

Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

* Required


VariablePoints
Age 
<50 years0
50–59 years+1
60–69 years+2
70–79 years+3
≥80 years+4
Myocardial infarction
History of definite or probable MI (EСG changes and/or enzyme changes)		+1
Congestive heart failure
Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents		+1
Peripheral vascular disease
Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)		+1
Cerebrovascular accident  or Transient ischemic attack
History of a cerebrovascular accident with minor or no residua and transient ischemic attacks		+1
Dementia
Chronic cognitive deficit		+1
Chronic obstructive pulmonary disease+1
Connective tissue disease+1
Peptic ulcer disease
Any history of treatment for ulcer disease or history of ulcer bleeding		+1
Liver disease
Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)		None 0
 Mild +1
 Moderate to severe +3
Diabetes mellitusNone or diet-controlled 0
 Uncomplicated +1
 End-organ damage +2
Hemiplegia+2
Moderate to severe chronic kidney disease
Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)		+2
  
Solid tumorNone 0
 Localized +2
 Metastatic +6
Leukemia+2
Lymphoma+2
AIDS+6

Charlson Comorbidity Index assess by addition of the selected points:

VariableDefinitionPoints
Myocardial infarctionHistory of definite or probable MI (EKG changes and/or enzyme changes)1
Congestive heart failureExertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents1
Peripheral vascular diseaseIntermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)1
Cerebrovascular accident or transient ischemic attackHistory of a cerebrovascular accident with minor or no residua and transient ischemic attacks1
DementiaChronic cognitive deficit1
Chronic obstructive pulmonary disease–1
Connective tissue disease–1
Peptic ulcer diseaseAny history of treatment for ulcer disease or history of ulcer bleeding1
Mild liver diseaseMild = chronic hepatitis (or cirrhosis without portal hypertension)1
Uncomplicated diabetes–1
Hemiplegia–2
Moderate to severe chronic kidney diseaseSevere = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)2
Diabetes with end-organ damage–2
Localized solid tumor–2
Leukemia–2
Lymphoma–2
Moderate to severe liver diseaseSevere = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history3
Metastatic solid tumor–6
AIDS*–6

Plus 1 point for every decade age 50 years and over, maximum 4 points.

Note: liver disease and diabetes inputs are mutually exclusive (e.g. do not give points for both “mild liver disease” and “moderate or severe liver disease”).

*This data is from the original Charlson study in 1987, before the widespread availability of effective antiretroviral therapy. Currently, there are no any re-evaluations of the CCI using more recent data.

10-year survival = 0.983^(e CCI × 0.9), where CCI = Charlson Comorbidity Index.


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Literature:

  1. Charlson ME, Pompei P, Ales KL, MacKenzie CR: A New Method of Classifying Prognostic Comorbidity in Longitudinal Studies: Development and Validation. Journal of Chronic Diseases 40:373-383, 1987
  2. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, Januel JM, Sundararajan V. Updating and Validating the Charlson Comorbidity Index and Score for Risk Adjustment in Hospital Discharge Abstracts Using Data From 6 Countries. Am. J. Epidemiol. (2011)doi: 10.1093/aje/kwq433
  3. Radovanovic D, Seifert B, Urban P, Eberli FR, Rickli H, Bertel O, Puhan MA, Erne P; AMIS Plus Investigators. Validity of Charlson Comorbidity Index in patients hospitalised with acute coronary syndrome. Insights from the nationwide AMIS Plus registry 2002-2012. Heart. 2014 Feb;100(4):288-94. doi: 10.1136/heartjnl-2013-304588. Epub 2013 Nov 1.
  4. Zavascki AP, Fuchs SC. The need for reappraisal of AIDS score weight of Charlson comorbidity index. J Clin Epidemiol. 2007;60(9):867-8.

Сообщение Charlson Comorbidity Index (CCI) Online Calculator появились сначала на ClinCaseQuest.

]]> SAVED VTE Score https://clincasequest.hospital/saved-vte-score/ Wed, 11 Jan 2023 14:09:11 +0000 https://clincasequest.hospital/?p=34420 SAVED score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators. Variable Points Surgery within 90 days +2 Mongoloid race -3 History…

Сообщение SAVED VTE Score появились сначала на ClinCaseQuest.

]]> SAVED score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators.

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* Required


VariablePoints
Surgery within 90 days+2
Mongoloid race-3
History of VTE+3
Age ≥ 80 years+1
Dexamethasone (dosage regimen):
• Standard dose (120-160 mg/cycle)
• High dose (>160 g/cycle)
+1
+2


Calculation

High risk (≥ 2 points). Recommended:

  • Enoxaparin 40 mg subcutaneously 1 time/day
  • Dalteparin 5000 units subcutaneously 1 time/day (category 2B)
  • Warfarin (INR 2-3)

Low risk (< 2 points). Recommended:

  • Do not prescribe medications
  • Aspirin 81-325 mg/day


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Multiple Myeloma Diagnostic Criteria – Online Calculator

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≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

* Required
For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
Read More

IMPEDE VTE Score

IMPEDE score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators. [ezfc…

Read More

Сообщение SAVED VTE Score появились сначала на ClinCaseQuest.

]]> IMPEDE VTE Score https://clincasequest.hospital/impede-vte-score/ Wed, 11 Jan 2023 14:06:45 +0000 https://clincasequest.hospital/?p=34419 IMPEDE score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators. Individual Risk Factors Points Myeloma risk scores Points Positive Factors  …

Сообщение IMPEDE VTE Score появились сначала на ClinCaseQuest.

]]> IMPEDE score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators.

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Individual Risk Factors

Positive Factors

Negative Factors

Myeloma risk scores

* Required



Individual Risk FactorsPointsMyeloma risk scoresPoints
Positive Factors   
Central venous catheter/tunneled central catheter+2Immunomodulator (IM)+4
Fracture of the pelvis, hip joint, or femur+4A drug that stimulates erythropoiesis+1
Obesity (body mass index ≥ 25)+1Dexamethasone < 160 mg per month+2
Previous VTE+5Dexamethasone > 160 mg per month+4
  Doxorubicin or multicomponent chemotherapy+3
Negative Factors   
Ethnicity/Race – Mongoloid/Pacific Islander-3  
Current thromboprophylaxis: low molecular weight heparin (LMWH) at prophylactic doses or aspirin-3  
Current thromboprophylaxis: LMWH at prophylactic doses or warfarin-4  

Calculation

High risk (>3 points). An anticoagulant is recommended if it has not been prescribed before:

  • Enoxaparin 40 mg subcutaneously 1 time/day
  • Dalteparin 5000 units 1 time/day (category 2B)
  • Warfarin (INR 2-3)

Low risk (≤3 points). Recommended:

  • Do not prescribe medications
  • Aspirin 81-325 mg/day


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Multiple Myeloma Diagnostic Criteria – Online Calculator

≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
Read More

SAVED VTE Score

SAVED score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators. [ezfc…

Read More

Сообщение IMPEDE VTE Score появились сначала на ClinCaseQuest.

]]> Revised Cardiac Risk Index for Pre-Operative Risk (RCRI) Online Calculator https://clincasequest.hospital/rcri-online-calculator/ Tue, 10 May 2022 09:44:47 +0000 https://clincasequest.hospital/?p=33790 The revised cardiac risk index for preoperative risk may be used in patients ≥45 years old (or 18–44 years with significant cardiovascular disease*) undergoing elective…

Сообщение Revised Cardiac Risk Index for Pre-Operative Risk (RCRI) Online Calculator появились сначала на ClinCaseQuest.

]]> The revised cardiac risk index for preoperative risk may be used in patients ≥45 years old (or 18–44 years with significant cardiovascular disease*) undergoing elective non-cardiac surgery or urgent/semi-urgent (non-emergent) non-cardiac surgery.

*Known history of ischemic heart disease, cerebrovascular disease, peripheral arterial disease, congestive heart failure, severe pulmonary hypertension, or severe obstructive intracardiac abnormality (eg, severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

NB! The RCRI score should be used with caution in patients requiring urgent surgery, as this scale is not well validated in this population.

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* Required

The revised cardiac risk index for preoperative risk accurately risk-stratifies patients and helps patients understand individualized risk prior to undergoing surgery, which can be helpful in discussions of informed consent.

In patients with elevated risk (RCRI ≥1, age ≥65, or age 45-64 with significant cardiovascular disease), helps direct further preoperative risk stratification (e.g. with serum NT-proBNP or BNP) and determine appropriate cardiac monitoring post-op (ECG, troponins).

*Known history of coronary artery disease, cerebral vascular disease, peripheral artery disease, congestive heart failure, severe PHTN or a severe obstructive intracardiac abnormality (e.g. severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

 Points
Elevated-risk surgery (Intraperitoneal; intrathoracic; suprainguinal vascular)1
History of ischemic heart disease (history of myocardial infarction (MI); history of positive exercise test; current chest pain considered due to myocardial ischemia; use of nitrate therapy or ECG with pathological Q waves)1
History of congestive heart failure (pulmonary edema, bilateral rales or S3 gallop; paroxysmal nocturnal dyspnea; chest x-ray (CXR) showing pulmonary vascular redistribution)1
History of cerebrovascular disease (prior transient ischemic attack (TIA) or stroke)1
Pre-operative treatment with insulin1
Pre-operative creatinine >2 mg/dL (176.8 µmol/L)1

Interpretation:

RCRI ScoreRisk of major cardiac event (95% CI) (defined as death, myocardial infarction, or cardiac arrest at 30 days after noncardiac surgery)
03,9% (2,8-5,4%)
16,0% (4,9-7,4%)
210,1% (8,1-12,6%)
≥315% (11,1-20,0%)

According to the 2016 CCS Perioperative Guidelines:

  • If the RCRI is ≥1, the patient’s age is ≥65, or they are between 45-64 with significant cardiac disease*, the next step is to measure the patient’s NT-ProBNP or BNP if this is available at your institution.
  • If the NT-ProBNP is ≥300 ng/L or BNP is ≥92 ng/L, then there should be an EKG ordered in the PACU and troponins should be measured daily for 48-72 hours.
  • If, after risk stratification, the NT-ProBNP is <300 ng/L or BNP <92 ng/L, no routine postoperative cardiac monitoring is warranted.
  • If the institution does not have these assays available, then all patients should be monitored with an EKG in the PACU and troponin measurements daily for 48-72 hours if they meet one of the following: RCRI ≥1, age ≥65, or age 45-64 with the aforementioned cardiac disease.*

*Known history of coronary artery disease, cerebral vascular disease, peripheral artery disease, congestive heart failure, severe PHTN or a severe obstructive intracardiac abnormality (e.g. severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

The data supporting the use of NT-ProBNP/BNP comes from a large 2014 meta-analysis of 18 studies with a total of 2,477 patients (Rodseth 2014). This study, which was in agreement with multiple previous meta-analyses, noted that for those patients with a pre-operative NT-ProBNP of <300 ng/l or BNP <92 ng/l, the rate of 30-day postoperative non-fatal MI or Death was 4.9% (3.9%-61%), and was 21.8% (19.0%-24.8%) in those with pre-operative NT-ProBNP is ≥300 ng/L or BNP is ≥92 ng/L.

RCRI score easy to use by any involved specialty, including general internal medicine, cardiology, anesthesia, or surgery, and very well validated. It can be used in the inpatient or outpatient preoperative setting.

At the same time, the RCRI score includes a limited number of risk factors it includes, in part because the original studies could not include a sufficient number of patients for every important risk factor (e.g. underestimates hemodynamic and cardiovascular outcomes in valvular disease).

NB! Other patient important outcomes that are not assessed by this tool include:

  • risk of stroke,
  • major bleeding,
  • prolonged hospitalization,
  • ICU admission.

Alternative perioperative cardiac risk scores like the Myocardial Infarction and Cardiac Arrest (MICA) Score and the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Score have been validated only retrospectively and therefore underestimate the risk of myocardial ischemia compared with the RCRI, which has been validated by multiple studies over the past 15 years including a very large 2010 systematic review (24 studies and 792,740 patients) which found moderate discrimination in predicting major perioperative cardiac complications.

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Literature

  1. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O’Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977 Oct 20;297(16):845-50. https://pubmed.ncbi.nlm.nih.gov/904659/
  2. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999 Sep 7;100(10):1043-9. https://pubmed.ncbi.nlm.nih.gov/10477528/
  3. VISION Pilot Study investigators, Devereaux PJ, Bradley D, Chan MT, et al. An international prospective cohort study evaluating major vascular complications among patients undergoing noncardiac surgery: the VISION Pilot Study. Open Med. 2011;5(4):e193-200. https://pubmed.ncbi.nlm.nih.gov/22567075/
  4. Ausset S, Auroy Y, Lambert E, et al. Cardiac troponin I release after hip surgery correlates with poor long-term cardiac outcome. Eur J Anaesthesiol. 2008;25(2):158-64. https://pubmed.ncbi.nlm.nih.gov/17666156/
  5. Sheth T, Chan M, Butler C, et al. Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study. BMJ. 2015;350:h1907. https://pubmed.ncbi.nlm.nih.gov/25902738/
  6. Ford MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med. 2010;152(1):26-35. http://www.ncbi.nlm.nih.gov/pubmed/20048269
  7. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007;50(17):1707-32. https://pubmed.ncbi.nlm.nih.gov/17950159/
  8. Duceppe E, Parlow J, Macdonald P, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017;33(1):17-32. https://pubmed.ncbi.nlm.nih.gov/27865641/
  9. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):2215-2245. https://pubmed.ncbi.nlm.nih.gov/25085962/
  10. Rajagopalan S, Croal BL, Bachoo P, Hillis GS, Cuthbertson BH, Brittenden J. N-terminal pro B-type natriuretic peptide is an independent predictor of postoperative myocardial injury in patients undergoing major vascular surgery. J Vasc Surg. 2008;48(4):912-7. https://pubmed.ncbi.nlm.nih.gov/18586440/
  11. Rodseth RN, Biccard BM, Le manach Y, et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol. 2014;63(2):170-80. https://pubmed.ncbi.nlm.nih.gov/24076282/
  12. Devereaux PJ, Duceppe E, Guyatt G, et al. Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial. Lancet. 2018;391(10137):2325-2334. https://pubmed.ncbi.nlm.nih.gov/29900874/

Charlson Comorbidity Index (CCI) Online Calculator

Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

Chronic cognitive deficit

Any history of treatment for ulcer disease or history of ulcer bleeding

Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

VariablePointsAge <50…
Read More

Multiple Myeloma Diagnostic Criteria – Online Calculator

≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
Read More

Сообщение Revised Cardiac Risk Index for Pre-Operative Risk (RCRI) Online Calculator появились сначала на ClinCaseQuest.

]]> PERC Rule for Pulmonary Embolism- online calculator https://clincasequest.hospital/perc-rule/ Thu, 10 Feb 2022 00:48:00 +0000 https://clincasequest.hospital/?p=33447 Rules out PE if no criteria are present and pre-test probability is ≤15%. The PERC rule can be applied to patients in whom PE is…

Сообщение PERC Rule for Pulmonary Embolism- online calculator появились сначала на ClinCaseQuest.

]]> Rules out PE if no criteria are present and pre-test probability is ≤15%.

The PERC rule can be applied to patients in whom PE is suspected, but the patient is considered to be at low risk (clinical pretest probability <15%).

The PERC rule can be applied to patients where the diagnosis of PE is being considered, but the patient is deemed low-risk. A patient deemed low-risk who is also <50 years of age, with a pulse <100 bpm, SaO2 ≥95%, no hemoptysis, no estrogen use, no history of surgery/trauma within 4 weeks, no prior PE/DVT and no present signs of DVT can be safely ruled out and does not require further further diagnostic tests.

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Surgery or trauma ≤4 weeks ago requiring treatment with general anesthesia

Oral contraceptives, hormone replacement or estrogenic hormones use in males or female patients

0
* Required


If any criteria are positive, the PERC rule is not satisfied and cannot be used to rule out PE in this patient.

Pulmonary embolism exclusion criteria can be used by physicians to avoid performing imaging studies in low-risk patients who are not indicated, which will both reduce the iatrogenic impact on the patient and promote the rational use of clinic resources.

The PERC rule is an “eliminate” tool: all variables must be absent “no” for the result to be negative.

As an exclusion criterion, PERC is not intended for risk stratification.

The rule can be used if the patient has a low risk of PE (<15% pretest probability). For these patients with a low pre-test probability of PE, the risk associated with initiating evaluation and treatment of PE (eg, CT radiation, anaphylaxis from contrast agent administration, bleeding with anticoagulant use) is equivalent to the likelihood of missing a diagnosis.

Age ≥50+1
HR ≥100+1
O₂ sat on room air <95%+1
Unilateral leg swelling+1
Hemoptysis+1
Recent surgery or trauma
Surgery or trauma ≤4 weeks ago requiring treatment with general anesthesia		+1
Prior PE or DVT+1
Hormone use
Oral contraceptives, hormone replacement or estrogenic hormones use in males or female patients		+1

Interpretation

If any of the following is/are present, PE cannot be ruled out:

  • Age ≥50.
  • HR ≥100.
  • O₂ sat on room air <95%.
  • Unilateral leg swelling.
  • Hemoptysis.
  • Recent trauma or surgery.
  • Prior PE or DVT.
  • Hormone use (oral contraceptives, hormone replacement or estrogenic hormones use in males or female patients).
Number of criteriaRecommendation
0 criteria for the PERC rule for pulmonary embolism0 criteria according to the PERC rule for pulmonary embolism.

No need for further workup, as <2% chance of PE.

If no criteria are positive and clinician’s pre-test probability is <15%, PERC Rule criteria are satisfied.
1-8 PERC Criteria for Pulmonary EmbolismIf any criteria are positive, the PERC rule cannot be used to rule out PE in this patient.

The PERC rule for pulmonary embolism was based on the results of a prospective study that included 3148 patients from 10 centers. 21 potential variables were included in the initial analysis, from which eight final variables were selected. For further validation of the data obtained, 1427 low-risk patients and 382 very-low-risk patients from 2 centers were included.

  • In low-risk patients, sensitivity was 96% and specificity 27%.
  • In patients at very low risk, sensitivity was 100% and specificity -15%.
  • The 90-day false-negative rate in low-risk patients was 1.4%, below the testing threshold of 1.8%.

The second stage of validation was carried out in 2008. A threshold of <15% was chosen for the low pretest probability. The study included 8138 patients from 13 centers:

  • 20% of the cohort were at low risk (<15%)
  • For patients with a negative PERC result and a pretest probability <15%, the false-negative rate at 45 days was 1.0% with a sensitivity of 97.4% and a specificity of 21.9%.

Clinical Approach

In a low-risk patient who has one or more PERC criteria, the clinician should consider performing a D-dimer evaluation to further evaluation:

  • If D-dimer is negative and the clinical pretest probability is <15%, such patient does not require further evaluation to rule out PE.
  • This rule helps rule out PE in patients at low risk of PE based on clinical criteria alone.
  • PERC-negative patients do not require D-dimer testing, which has high sensitivity but low specificity.
  • Low-risk PERC-negative patients will not be exposed to the risks associated with unnecessary imaging tests and treatment for PE.
  • If D-dimer is positive, additional investigations such as CT angiography or V/Q scan should be done.

NB!

  • This rule does not apply to patients who are not assessed for PE.
  • If the patient has a moderate or high clinical risk of pre-test probability of PE – the PERC rule cannot be used! Consideration should be given to D-dimer assessment or imaging based on risk.
  • As an exclusion criterion, PERC is not intended for risk stratification.

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Literature

  1. Kline JA, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004; 2: 1247–55. https://pubmed.ncbi.nlm.nih.gov/15304025/
  2. Kline JA, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost 2008; 6: 772–80. (PMID: 18318689). https://pubmed.ncbi.nlm.nih.gov/18318689/
PESI scale (Pulmonary Embolism severity index) online calculator
Simplified version of the PESI scale sPESI (Pulmonary Embolism severity index)
Revised Geneva Score, rGeneva online calculator
Well’s criteria for Pulmonary Embolism probability assessment

Takotsubo syndrome

Takotsubo syndrome is a condition characterized by the sudden onset of acute, transient (lasting up…

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Сообщение PERC Rule for Pulmonary Embolism- online calculator появились сначала на ClinCaseQuest.

]]> Infective Endocarditis (IE) Mortality Risk Score: online calculator https://clincasequest.hospital/ie-mortality-risk-score/ Mon, 17 Jan 2022 16:54:51 +0000 https://clincasequest.hospital/?p=32833 The Infectious Endocarditis Mortality Risk Score can be used in patients with confirmed IE to assess mortality risk. Addition of assigned points. Host Factors Age…

Сообщение Infective Endocarditis (IE) Mortality Risk Score: online calculator появились сначала на ClinCaseQuest.

]]> The Infectious Endocarditis Mortality Risk Score can be used in patients with confirmed IE to assess mortality risk.

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Host Factors

IE Factors

IE Complications

* Required

Addition of assigned points.

Host Factors
Age 
 ≤45     0
 46-60+2      
 61-70+3         
 >70+4
History of DialysisNo0
 Yes+3
IE Factors
Nosocomial IENo0
 Yes+2
Prosthetic IENo0
 Yes+1
Symptoms >1 month before admissionNo0
 Yes-1
Staphylococcus aureusNo0
 Yes+1
Viridans group streptococciNo0
 Yes-2
Aortic vegetationNo0
 Yes+1
Mitral vegetationNo0
 Yes+1
IE Complications
NYHA class 3 or 4 heart failureNo0
 Yes+3
StrokeNo0
 Yes+2
Paravalvular complicationNo0
 Yes+2
Persistent bacteremiaNo0
 Yes+2
Surgical treatmentNo0
 Yes-2

Probability of 6‐month mortality = 2.416*score+0.109*score2−4.849

A simplified risk score ≥8 had sensitivity 86.7% and specificity 50.8% for predicting overall 6‐month mortality (negative predictive value of 86% and positive predictive value of 39%).

The derivation cohort contained 4049 patients, and the validation cohort included 1197 subjects. This study was performed in referral centres (likely tertiary and quaternary academic centres) with experience with endocarditis and cardiac surgery.

Infective endocarditis (IE) has an overall 6-month mortality of approximately 25% in all-comers. Older age and history of dialysis appear to be the highest risk patient factors; IE complications also suggest a high mortality as well. Surgery is associated with a lower mortality rate but is infrequent in the high-risk cohort of patients. Mortality ranges from 10% in the lowest risk quintile to 53% in the highest-risk quintile. Surgery in this study was associated with lower mortality, but the highest risk patients were less likely to receive surgery (probably because they were high-risk surgical patients as well).

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Literature

  1. Lawrence P. Park, Vivian H. Chu, Gail Peterson, Athanasios Skoutelis, Tatjana Lejko‐Zupa, Emilio Bouza, Pierre Tattevin, Gilbert Habib, Ren Tan, Javier Gonzalez, Javier Altclas, Jameela Edathodu, Claudio Querido Fortes, Rinaldo Focaccia Siciliano, Orathai Pachirat, Souha Kanj, Andrew Wang, and the International Collaboration on Endocarditis (ICE) Investigators. Validated Risk Score for Predicting 6‐Month Mortality in Infective Endocarditis. Journal of the American Heart Association.2016.Vol. 5, No. 4. 2016;5:e003016 https://doi.org/10.1161/JAHA.115.003016

See also:

Infective endocarditis. Diagnostic criteria for infective endocarditis

Takotsubo syndrome

Takotsubo syndrome is a condition characterized by the sudden onset of acute, transient (lasting up…

Read More

Lyme disease

Lyme disease is an infectious disease caused by the spirochete Borrelia burgdorferi, which is transmissible…

Read More

Сообщение Infective Endocarditis (IE) Mortality Risk Score: online calculator появились сначала на ClinCaseQuest.

]]> IPSET – Thrombosis Risk for essential thrombocythemia: Online Calculator https://clincasequest.hospital/ipset/ Thu, 13 Jan 2022 16:09:57 +0000 https://clincasequest.hospital/?p=32701 International Prognostic Score of thrombosis in World Health Organization – essential thrombocythemia (IPSET-thrombosis). IPSET-thrombosis model provides objective estimates of the probability of thrombotic events in…

Сообщение IPSET – Thrombosis Risk for essential thrombocythemia: Online Calculator появились сначала на ClinCaseQuest.

]]> International Prognostic Score of thrombosis in World Health Organization – essential thrombocythemia (IPSET-thrombosis).

IPSET-thrombosis model provides objective estimates of the probability of thrombotic events in patients with newly diagnosed ET.

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(one or more of: hypertension, diabetes mellitus, active smoking)

Points 0
* Required

The scale consist of the following parameters, listed below:

Patient age 
• under 60 years0
• 60 years or older1
Prior thrombotic event2
Cardiovascular risk factors present
(One or more of: hypertension, diabetes mellitus, active smoking)		1
Detected JAK2 V617F mutation2

The primary objective of essential thrombocythemia (ET) management is to prevent thromboembolic complications. In this regard, advanced age and thrombosis history were used to assess this risk. More recently, JAK2V617F and cardiovascular (CV) risk factors were identified as additional modifiers, leading to the development of a 3-tiered International Prognostic Score of Thrombosis for ET (IPSET-thrombosis): “low”, “intermediate”, and “high”.

Total 6 points (Age 1, H/O Thrombosis 2, Cardiovascular risk factor 1 and JAK2V617F – 2 points).

Determine risk group and prognosis:

ScoreRisk categoryAnnual thrombosis risk
0 – 1Low1.03%
2Intermediate2.35%
3 – 6High3.56%

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Reference:
Barbui T, Finazzi G, Carobbio A, Thiele J, Passamonti F, Rumi E et al. Development and validation of an International Prognostic Score of thrombosis in World Health Organization-essential thrombocythemia (IPSET-thrombosis). Blood 2012; 12: 5128-33

Сообщение IPSET – Thrombosis Risk for essential thrombocythemia: Online Calculator появились сначала на ClinCaseQuest.

]]> Killip Classification for Heart Failure https://clincasequest.hospital/killip-classification/ Mon, 29 Nov 2021 07:08:00 +0000 https://clincasequest.hospital/?p=31650 Killip Classification for Heart Failure could be used in patients with confirmed acute coronary syndrome in both STEMI and NSTEMI for mortality prediction. Can be…

Сообщение Killip Classification for Heart Failure появились сначала на ClinCaseQuest.

]]> Killip Classification for Heart Failure could be used in patients with confirmed acute coronary syndrome in both STEMI and NSTEMI for mortality prediction.

Can be used as part of the full clinical picture to help decide among treatment options, including reperfusion therapy and intra-aortic balloon pump placement. Predicts mortality in ACS and is validated for both STEMI and NSTEMI.

Killip Classification for Heart Failure

No signs of congestion
S3 and basal rales on auscultation
Acute Pulmonary oedema
Cardiogenic shock




Class 30-day mortality* In-hospital mortality** (historical interest only)
0 0 0

Killip classification:

Class INo signs of congestion
Class IIS3 and basal rales on auscultation
Class IIIAcute pulmonary oedema
Class IVCardiogenic shock

Interpretation:

Class30-day mortality*In-hospital mortality** (historical interest only)
I2-3%<6%
II5-12%<17%
III10-20%38%
IV10-20%81%

*From Khot 2003, which combined class III/IV owing to relatively smaller number of patients in class IV (0.3% of patients).
**From Killip 1967. Killip classification developed in the 1960s, before reperfusion therapy (thrombolytics, PCI); has been shown across several studies since then to still be predictive of mortality. However, mortality rates have declined significantly since the original study.

About the creator

Thomas Killip III, MD, is a professor of medicine and cardiology at Mount Sinai Beth Israel Hospital in New York City. He has published dozens of studies in cardiology since the 1960s. Dr. Killip is best known for the heart failure classification system that bears his name. To view Dr. Thomas Killip III’s publications, visit PubMed

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References:

  1. Thomas Killip III, John T. Kimball Treatment of myocardial infarction in a coronary care unit. Two year experience with 250 patients. Symposium on coronary care unit. 1967, Vol.20(4):P457-464. DOI: https://doi.org/10.1016/0002-9149(67)90023-9
  2. Khot UN, Jia G, Moliterno DJ, Lincoff AM, Khot MB, Harrington RA, Topol EJ. Prognostic importance of physical examination for heart failure in non-ST-elevation acute coronary syndromes: the enduring value of Killip classification. JAMA. 2003 Oct 22;290(16):2174-81. doi: 10.1001/jama.290.16.2174.  PMID: 14570953. https://pubmed.ncbi.nlm.nih.gov/14570953/
  3. DeGeare VS, Boura JA, Grines LL, O’Neill WW, Grines CL. Predictive value of the Killip classification in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Am J Cardiol. 2001 May 1;87(9):1035-8. doi: 10.1016/s0002-9149(01)01457-6. PMID: 11348598. https://pubmed.ncbi.nlm.nih.gov/11348598/
  4. Nesković AN, Otasević P, Bojić M, Popović AD. Association of Killip class on admission and left ventricular dilatation after myocardial infarction: a closer look into an old clinical classification. Am Heart J. 1999 Feb;137(2):361-7. doi: 10.1053/hj.1999.v137.89744. PMID: 9924172. https://pubmed.ncbi.nlm.nih.gov/9924172/
GRACE ACS Risk and Mortality Calculator
The Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk score
SAVE (Survival After Veno-Arterial ECMO) Score

Interactive OSCE Checklist – Emergency care of a patient with chest pain – Acute Coronary Syndrome with ST-segment elevation and equivalents

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• Opening the consultation

• Availability of a defibrillator

• Presenting complaint

• History of presenting complaint

• Past medical history

• Drug history

• Physical examination

• Intravenous access

• Registration of a 12-channel ECG

• Express test for the determination of cardiac troponin, myoglobin, creatine phosphokinase-MB, if possible

• Making preliminary diagnosis

• Drug therapy (basic)

• Evaluation of the door-balloon time (the choice of further reperfusion strategy aimed as soon as possible to restore the coronary blood flow in the infarct-dependent artery)

• Call the nearest reperfusion center

• P2Y12 receptor inhibitor prescription depending on the chosen strategy of reperfusion therapy

• Carrying out thrombolytic therapy as needed

• Transportation to the nearest reperfusion center

Total: 0 / 62
Additional materials: https://clincasequest.hospital/chest-pain-history-taking/ https://clincasequest.hospital/pericarditis/ https://clincasequest.hospital/stephen-smiths-formula/ https://clincasequest.hospital/wellens-syndrome/ https://clincasequest.hospital/aslangers-pattern/ Register on our website right…
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]]> Stephen Smith’s formula for Subtle Anterior STEMI online Calculator https://clincasequest.hospital/stephen-smiths-formula/ Tue, 16 Nov 2021 13:39:00 +0000 https://clincasequest.hospital/?p=31467 Differentiates normal variant ST elevation (benign early repolarization) from anterior STEMI, more sensitive than 3-variable version. Dr. Steven Smith has about 90% sensitivity and specificity.…

Сообщение Stephen Smith’s formula for Subtle Anterior STEMI online Calculator появились сначала на ClinCaseQuest.

]]> Differentiates normal variant ST elevation (benign early repolarization) from anterior STEMI, more sensitive than 3-variable version. Dr. Steven Smith has about 90% sensitivity and specificity.

Stephen Smith’s formula for Subtle Anterior STEMI use in chest pain patients presenting with an ECG that is non-diagnostic but suspicious for anterior MI.

NB! Before using this calculator, make sure the EKG shows ≥1 mm ST elevation (STE) in ≥1 of the precordial leads V2-V4.

If it shows any one of the following, then it is NOT normal variant, and is very likely to be LAD occlusion; such cases were excluded from the study as “obvious” MI:

  • >5 mm STE.
  • Non-concave STE.
  • Inferior reciprocal changes ST in II, III, aVF, V6.
  • Anterior ST depression.
  • Terminal QRS distortion in V2 or V3:
  • Smith Formula, Steven Smith Formula, Smith Calculator, Smith Online Calculator, Formula for MI, myocardial infarction, Heart attack, anterior acute myocardial infarction, AMI, insidious infarction, insidious myocardial infarction, myocardial infarction, acute myocardial infarction, acute MI, STEMI ST elevation, ST segment, stemi, ST segment elevation, with elevation, elevation, calculator, score, formula, scale, calculate, online calculator, calculate online, medical calculator, medical calculators, ECG, cardiogram, electrocardiogram, cardiography, electrocardiography
  • Q waves in any of V2 to V4.
  • Any T wave inversion from V2 to V6.

Bazett-corrected QT interval

QRS amplitude in lead V2
[Please, enter if you want to get the value according to Stephen Smith’s 4-Variable formula for receiving the highest sensitivity and specificity of the calculated values]:

R wave amplitude in lead V4:

ST segment elevation 60 ms after the J point in lead V3:



Score Stephen Smith’s formula Range of values Conclusion
0 0 0 0
Score Stephen Smith’s formula Range of values Conclusion
0 0 0 0

Both benign early repolarization and STEMI cause ST elevation. The challenge is to differentiate the two entities.

Some patients present with subtle ECG changes nondiagnostic for STEMI but still have 100% coronary artery occlusion and benefit from acute percutaneous coronary intervention (PCI).

Using the equation in such cases can lead to timely cath lab activation, or more intensive evaluation.

Stephen Smith’s formula for the diagnosis of “Insidious” anterior ST-segment elevation acute myocardial infarction (4 variables) includes:

  • Interval QTc with Bazett correction, msec
  • Amplitude of QRS in lead V2, mm
  • Amplitude of the R wave in lead V4, mm
  • ST segment elevation 60 ms after the J-point in lead V3 mm

Formula:

3-variable formula for subtle anterior STEMI =   3-variable = (1.196 x STE 60 elevation in V3, mm) + (0.059 x Bazett QTc interval, ms) – (0.326 x R amplitude in lead V4, mm)
4-variable formula for subtle anterior STEMI =   4-variable = (0.052 x Bazett QTc interval, ms) – (0.151 x QRS amplitude in lead V2, mm) – (0.268 x R amplitude in lead V4, mm) + (1.062 x STE 60 elevation in V3, mm)  
  • STE – ST-elevation 60 ms after the J-point in lead V3, in mm;
  • QTc – QT interval corrected relative to heart rate, in ms (according to automatic ECG analysis);
  • RV4 – the amplitude of the R wave in lead V4, in mm;

Interpretation of 3-component formula results:

  • Indicators ≥23.4, probably there is PNA occlusion.
  • Indicators 22-23.4 – the value does not reach the diagnostic threshold of 23.4, but there is a possibility that the patient has PNA occlusion.
  • Indicators <23.4, low probability of PNA occlusion, possible benign early ventricular repolarization.

Interpreting the results of the 4-component formula:

  • Scores ≥18.2 are likely to be for anterior STEMI (sensitivity 83.3%, specificity 87.7%, and diagnostic accuracy 85.9%).
  • Scores <18.2 are likely to indicate early benign repolarization.

Smith’s 4-variable formula is more sensitive than the 3-variable version of the formula.

NB! The authors specifically excluded patients with obvious MI. Using the calculator in cases that were excluded in the study may lead to a wrong result.

Tips for ECG interpretation:

1). Measure STE at 60 ms in lead V3:

  • Smith Formula, Steven Smith Formula, Smith Calculator, Smith Online Calculator, Formula for MI, myocardial infarction, Heart attack, anterior acute myocardial infarction, AMI, insidious infarction, insidious myocardial infarction, myocardial infarction, acute myocardial infarction, acute MI, STEMI ST elevation, ST segment, stemi, ST segment elevation, with elevation, elevation, calculator, score, formula, scale, calculate, online calculator, calculate online, medical calculator, medical calculators, ECG, cardiogram, electrocardiogram, cardiography, electrocardiography

ST elevation at 60 ms after the J-point in lead V3, relative to the PR segment.

  • Measure STE 60 ms (1½ small box after J point).
  • The baseline is the PR segment.
  • In this example, STE 60 = 4 mm.

2). Measure amplitude of R wave in V4:

  • Smith Formula, Steven Smith Formula, Smith Calculator, Smith Online Calculator, Formula for MI, myocardial infarction, Heart attack, anterior acute myocardial infarction, AMI, insidious infarction, insidious myocardial infarction, myocardial infarction, acute myocardial infarction, acute MI, STEMI ST elevation, ST segment, stemi, ST segment elevation, with elevation, elevation, calculator, score, formula, scale, calculate, online calculator, calculate online, medical calculator, medical calculators, ECG, cardiogram, electrocardiogram, cardiography, electrocardiography

In this example, RV4 = 9 mm.

3). Calculate the QTc: QTc is simply read from the computerized interpretation (uses Bazett’s formula).

Corrected QT Interval Bazett’s formula online calculator

Conclusion

Activation of a cath lab team is appropriate in patients with a positive Smith formula in the appropriate clinical context. At the very least, this result should prompt the command of the heart team to carry out repeated ECG recordings, the so-called serial ECG, and echocardiography.

The Smith Formula is best used to identify patients with LAD occlusion, which was initially considered a normal option for early repolarization.

If the Smith formula (4-variable) is negative for STEMI, proceed with caution if STEMI is still suspected.

References:

  1. Smith SW, Khalil A, Henry TD, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med. 2012;60(1):45-56.e2. https://pubmed.ncbi.nlm.nih.gov/22520989/
  2. Driver BE, Khalil A, Henry T, Kazmi F, Adil A, Smith SW. A new 4-variable formula to differentiate normal variant ST segment elevation in V2-V4 (early repolarization) from subtle left anterior descending coronary occlusion – Adding QRS amplitude of V2 improves the model. J Electrocardiol. 2017;50(5):561-569. https://www.sciencedirect.com/science/article/abs/pii/S0022073617301073
  3. Bozbeyoğlu E, Aslanger E, Yıldırımtürk Ö, et al. A tale of two formulas: Differentiation of subtle anterior MI from benign ST segment elevation. Ann Noninvasive Electrocardiol. 2018;:e12568. https://onlinelibrary.wiley.com/doi/epdf/10.1111/anec.12568

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Unconsciousness and ECG changes in a patient with comorbidities

Tisdale Risk Score for QT Prolongation

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Lyme disease is an infectious disease caused by the spirochete Borrelia burgdorferi, which is transmissible…

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