Correspondence
Management of Acute Mesenteric Ischemia
N Engl J Med 1996; 335:594-596August 22, 1996
- Article
To the Editor:
The Clinical Problem-Solving article entitled “The Invisible Patient” (April 4 issue)1 describes a patient who died of bowel ischemia that manifested clinically several hours after coronary angiography. The discussant attributed the ischemic event to the dislodgment of an atheromatous plaque by arterial catheterization. Two days earlier, however, the patient had undergone cardioversion for atrial fibrillation of unknown duration. The discussant rejected the possibility of a left atrial thrombus as a potential embolic source because two days had elapsed since cardioversion.
Thromboembolism occurring hours to days after the restoration of sinus rhythm is a well-known complication of cardioversion for long-standing atrial fibrillation.2 This complication may occur even in the absence of a preexisting left atrial thrombus at the time of cardioversion, because of a delay between the restoration of sinus rhythm and the resumption of atrial mechanical activity.3 In fact, the function of the left atrial appendage may worsen transiently after cardioversion, as demonstrated by Fatkin et al.3 For this reason, anticoagulation therapy is commonly administered for several weeks before and after cardioversion for atrial fibrillation lasting longer than 48 to 72 hours.
In this case, an intracerebral arteriovenous malformation was considered a contraindication to anticoagulation therapy. Although the results of echocardiography were interpreted as normal, this imaging study does not provide ample visualization of thrombi in the left atrial appendage. It is therefore possible that cardioversion promoted mesenteric embolism, either by dislodging a preexisting thrombus or by facilitating its formation in a stunned atrium in the absence of anticoagulation therapy. Cardioversion without previous anticoagulation therapy has recently been demonstrated to be safe when transesophageal echocardiography is used to rule out a preexisting left atrial thrombus.4 We believe that because of the contraindication to anticoagulation therapy, transesophageal echocardiography was required. This course of action might have prevented the patient's death. Had a left atrial thrombus been demonstrated, the decision to perform cardioversion could have been deferred. Had transesophageal echocardiography ruled out a left atrial thrombus, a more accurate clinical assessment of the risk of embolism involved in cardioversion could have been made.
4 ReferencesAmir Halkin, M.D.
David Leibowitz, M.D.
Hadassah University Hospital, Jerusalem 91240, Israel1
Sirmon M ,Kreisberg R . The invisible patient. N Engl J Med 1996;334:908-911
Full Text | Web of Science | Medline2
Roy D ,Marchand E ,Gagne P ,Chabot M ,Cartier R . Usefulness of anticoagulant therapy in the prevention of embolic complications of atrial fibrillation. Am Heart J 1986;112:1039-1043
CrossRef | Web of Science | Medline3
Fatkin D ,Kuchar DL ,Thorburn CW ,Feneley MP . Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for “atrial stunning“ as a mechanism of thromboembolic complications. J Am Coll Cardiol 1994;23:307-316
CrossRef | Web of Science | Medline4
Manning WJ ,Silverman DI ,Gordon SP ,Krumholz HM ,Douglas PS . Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi. N Engl J Med 1993;328:750-755
Full Text | Web of Science | Medline
To the Editor:
“The Invisible Patient” illustrates many of the difficult issues one faces in clinical decision making, especially when the risk–benefit margin is so narrow.
The decision to perform coronary arteriography is perplexing. Although a dipyridamole–thallium scan was interpreted as positive for ischemia, we are not told that the patient had any symptoms or had received any cardiac medications. Cardiac catheterization was performed, even though it is not clear that the patient would have been accepted as a surgical candidate. One wonders what the physicians hoped to gain from the information obtained. Was this patient a candidate for bypass surgery? A percutaneous procedure might have been considered but would have placed the patient at increased risk because of the need for anticoagulation therapy during the procedure. Finally, the usefulness of revascularization solely to reduce the preoperative risk is still debatable and has never been proved in a randomized trial.1
As we all know, decisions such as those faced in this case are challenging, and the involvement of an informed patient and family to aid in this process is invaluable. Nevertheless, the focus must remain on the patient's best interests, with a careful weighing of the risks and benefits of each intervention required to achieve this goal. To this end, sometimes the best and most difficult decision is not to intervene at all.
1 ReferencesRichard H. Hunn, M.D.
University of Pittsburgh Medical Center, Pittsburgh, PA 152131
Bodenheimer MM . Noncardiac surgery in the cardiac patient: what is the question? Ann Intern Med 1996;124:763-766
Web of Science | Medline
To the Editor:
“The Invisible Patient” raises an important issue about the need to perform diagnostic coronary angiography before major surgery in elderly patients. To avoid subjecting elderly patients without symptoms to the risk associated with invasive procedures, new, fast techniques of computed tomography (CT) (electron-beam and double helical CT) may provide an accurate, noninvasive alternative approach. The calcific atherosclerotic plaques within the wall of the coronary arteries can be easily visualized and measured with the use of these fast scanners, without the need to inject contrast material.
Studies of the relation between the extent of coronary calcification and the incidence of angiographically evident obstructive coronary artery disease, with a subanalysis of the data according to age and sex, indicate that the absence of signs of coronary calcification on fast CT rules out obstructive coronary artery disease in women over 60 years of age.1-4
4 ReferencesChaim I. Stroh, M.D.
Joseph Shemesh, M.D.
Michael Motro, M.D.
Sheba Medical Center, 52621 Tel-Hashomer, Israel1
Devries S ,Wolfkiel C ,Fusman B , et al. Influence of age and gender on the presence of coronary calcium detected by ultrafast computed tomography. J Am Coll Cardiol 1995;25:76-82
CrossRef | Web of Science | Medline2
Kajinami K ,Seki H ,Takekoshi N ,Mabuchi H . Noninvasive prediction of coronary atherosclerosis by quantification of coronary artery calcification using electron beam computed tomography: comparison with electrocardiographic and thallium exercise stress test results. J Am Coll Cardiol 1995;26:1209-1221
CrossRef | Web of Science | Medline3
Rumberger JA ,Sheedy PF III ,Breen JF ,Schwartz RS . Coronary calcium, as determined by electron beam computed tomography, and coronary disease on arteriogram: effect of patient's sex on diagnosis. Circulation 1995;91:1363-1367
Web of Science | Medline4
Shemesh J, Tenenbaum A, Fisman EZ, et al. Absence of coronary calcification on double-helical CT scans: predictor of angiographically normal coronary arteries in elderly women? Radiology (in press).
To the Editor:
In “The Invisible Patient,” the clinicians in charge are rightly chided for an appalling lack of awareness of the patient's autonomous rights. Their folly, however, goes further. Having diagnosed atrial fibrillation (and a cerebral arteriovenous malformation), the physicians ruled out structural cardiac disease by transthoracic echocardiography. They then proceeded, inexplicably, to dipyridamole–thallium scanning (which carries a small but not negligible risk).1 On the basis of these studies and in the absence of relevant symptoms, cardiac catheterization was performed “in case brain surgery was suggested” by neurosurgeons who apparently had yet to assess the patient. In my experience working in hospitals, both large and small, in the United Kingdom, it is unlikely that a patient would be able to undergo nonurgent CT, echocardiography, dipyridamole–thallium scanning, and coronary angiography all within five days after admission. Perhaps this situation is beneficial, since it allows time to talk and time to think.
1 ReferencesNikhil A. Hirani, M.R.C.P.
32 Magdala Rd., Nottingham, NG3 5DF, United KingdomTo the Editor:
In “The Invisible Patient,” the discussant focuses on moral issues pertaining to decision making and ignores the flawed management of an obvious mesenteric embolus. When an embolus lodges and the bowel becomes ischemic, the symptoms may range from minor pain to ileus to bloating. Not infrequently, as the bowel dies, it remains a sequestered inflammatory focus, because there is not much “recognition” of the problem in the small volume of tissue at the border zones of ischemia. Once leukocytosis has occurred and systemic symptoms from peritonitis are present, the ischemia is usually advanced. In this case, the discussant picked the proper diagnosis, but the treating physicians missed the one opportunity to save the patient. Instead, the symptoms persisted until the next day, and a useless endoscopic examination of the intestine further delayed the diagnosis. Any resident in our program who emulated this management would receive a failing grade.
Jeffrey L. Kaufman, M.D.
Baystate Medical Center, Springfield, MA 01199To the Editor:
In their commentary, Sirmon and Kreisberg are concerned chiefly with the patient's “increasingly marginal role in making decisions about her own care.” I suggest, however, that our concern should begin with the case history offered to the anonymous expert clinician. Why should it surprise us that the case history says nothing about the patient's mental status and capacity to make decisions? It says nothing about the person of the patient, to what extent she had ever made decisions about her care, or her experience of sickness and medical care. Except for the son's request not to tell his mother some bad news, the case history relates the patient's illness and medical care as a depersonalized chronicle of medical events.
What is missing is not only the patient's perspective — her understanding of her condition, how it has affected her life, her hopes and fears, and her preferences for medical care — but also a summary of the conversations among patient, son, and physicians. Did the patient say nothing to her physicians about her worries? Did they say nothing to her? The patient's physicians are as invisible as the patient, hidden behind such agentless, passive constructions as “Coronary angiography was recommended.” By whom?
Disembodied accounts of disease reflect an inadequate, outmoded notion of what should be taken seriously in medical care. For starters, the patient's perspective clearly warrants something of the explicit, written attention given the manifestations of disease.1,2 I believe that such attention to the patient's perspective should begin with the history of the present illness and continue with the medical record's progress notes and summaries.3 In teaching hospitals, the patient's perspective should also be part of the case histories presented orally during rounds, morning report, and grand rounds.
3 ReferencesWilliam J. Donnelly, M.D.
Edward Hines, Jr., Veterans Affairs Hospital, Hines, IL 601411
Delbanco TL . Enriching the doctor-patient relationship by inviting the patient's perspective. Ann Intern Med 1992;116:414-418
Web of Science | Medline2
Smith RC ,Hoppe RB . The patient's story: integrating the patient- and physician-centered approaches to interviewing. Ann Intern Med 1991;115:470-477
Web of Science | Medline3
Donnelly WJ. Taking suffering seriously: a new role for medical case history. Acad Med (in press).
Author/Editor Response
The authors reply:
To the Editor: We agree with Halkin and Leibowitz that a mesenteric embolus after cardioversion of atrial fibrillation was a more likely explanation of the fatal episode in our patient than atheroembolism from cardiac catheterization. The risk of embolization is 5 to 7 percent after cardioversion without anticoagulation therapy 1 and less than 1 percent after left-heart catheterization.2 We do not agree that the absence of a left atrial thrombus on transesophageal echocardiography rules out the possibility of systemic embolization.3,4 To our knowledge, there are no studies that demonstrate the safety of anticoagulation therapy in patients with cerebral arteriovenous malformations, although there are anecdotal experiences indicating its safety.
We agree with Hunn that there was no clinical or historical evidence that the operative risk would have been increased had the patient been a candidate for surgery on her arteriovenous malformation and that, consequently, there was no good reason for cardiac catheterization. The likelihood of a cardiac event in an asymptomatic patient with possible coronary artery disease undergoing noncardiac surgery is low, and further cardiac evaluation is unnecessary.5 Although Stroh et al. are correct in noting that ultrafast coronary CT is sensitive and specific for coronary atherosclerosis, it has limitations.6 Arterial calcification is correlated with the extent of plaque formation but does not predict which patients are likely to have an acute coronary syndrome.
Kaufman is correct in stating that the management of the fatal episode in our patient was seriously flawed and that a presumptive diagnosis of mesenteric occlusion due to systemic embolization from an atrial thrombus or from atheroembolism should have been uppermost in the minds of her physicians.
Donnelly chides physicians for failing to document the patient's goals and values and resulting treatment decisions. We agree with the need to emphasize their importance to medical students and house officers. We also agree with his suggestion that the physicians were invisible in the care of this patient. No one physician assumed control. The managing physician deferred to the subspecialists; the cardiologists called the tune with regard to cardioversion, noninvasive cardiac studies, and cardiac catheterization; and the gastroenterologist made the decision to perform endoscopy rather than angiography in this patient with mesenteric infarction. The managing physician should be the quarterback who weighs the data and opinions of others before deciding which play to call. The complex medical problems in our patient led to the provision of medical care by committee, which sometimes occurs in highly specialized institutions. Individually, the physicians were outstanding, but the patient's care was not.
Hunn raises the issue of balancing the risks and benefits of therapy, including the option not to intervene. We agree that nonintervention may be best for some patients. These decisions are difficult to make, require a great deal of time and thought, and in our opinion, are often overlooked in our technologically driven health care system, sometimes leading to unfortunate consequences.
6 ReferencesMaryella Sirmon, M.D.
University of South Alabama, Mobile, AL 36617Robert A. Kreisberg, M.D.
Baptist Health System, Birmingham, AL 352131
Weinberg DM ,Mancini J . Anticoagulation for cardioversion of atrial fibrillation. Am J Cardiol 1989;63:745-746
CrossRef | Web of Science | Medline2
Bourassa MG ,Noble J . Complication rate of coronary arteriography: a review of 5250 cases studied by a percutaneous femoral technique. Circulation 1976;53:106-114
Web of Science | Medline3
Black IW ,Fatkin D ,Sagar KB , et al. Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation: a multicenter study. Circulation 1994;89:2509-2513
Web of Science | Medline4
Fatkin D ,Kuchar DL ,Thorburn CW ,Feneley MP . Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for “atrial stunning“ as a mechanism of thromboembolic complications. J Am Coll Cardiol 1994;23:307-316
CrossRef | Web of Science | Medline5
Bodenheimer MM . Noncardiac surgery in the cardiac patient: what is the question? Ann Intern Med 1996;124:763-766
Web of Science | Medline6
Rumberger JA ,Sheedy PF II ,Breen JF ,Fitzpatrick LA ,Schwartz RS . Electron beam computed tomography and coronary artery disease: scanning for coronary artery calcification. Mayo Clin Proc 1996;71:369-377
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Jin-Sup Park, Han Cheol Lee, Hyo Yeong Lee, Jong Min Hwang, Bo-Won Kim, Hae Kyu Kim, Sang-Pil Kim, Yeong Dae Kim. (2011) Endovascular Management of Acute Total Occlusion of the Aorta. Journal of the Korean Geriatrics Society 15:2, 113
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