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Guest blogger Marisa has written up an expert review of our recent Journal Club discussion of clevidipine, as presented by Dr. Joshua Kosowsky of Brigham & Women’s Hospital:

Just last week, Clevidipine (Cleviprex) was approved by the FDA, making it the first new IV drug approved for high blood pressure in the past 10 years. Dr Joshua Kosowsky introduced us to Clevidipine when he discussed the VELOCITY (The evaluation of the effect of ultra-short-acting clevidipine in the treatment of patients with severe hypertension) trial as published in the June 2008 Annals of Emergency Medicine (PMID: 18534716), “Clevidipine, an Intravenous Dihydropyridine Calcium Channel Blocker, Is Safe and Effective for the Treatment of Patients With Acute Severe Hypertension” (residents: the PDF of this journal is online). More below:

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A number of you have asked for a recap on Dr. Hollander’s approach to treating NSTE ACS. You can download the audio from his talk on the Conference website. I’ve gone through it again and have some citations below. His talk is indeed guideline-based (all from the ACC/AHA 2007 NSTEMI / UA guidelines — familiarize yourself with their classes of recommendations and their grading the level of evidence) but also this portion of his talk was explicitly featured in a pharmaceutical-industry sponsored event. So, as always, approach this with a skeptical mind, and please share your findings in the comments section:

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I wanted to add some pearls from Dr. Strayer on Anita’s case from today:

* The literature and expert consensus have evolved over the past decade to favor anticoagulation for below the knee (distal or calf) DVTs. The classic teaching has been that distal DVTs are benign, so ultrasonographers often do not routinely evaluate the calf veins. Because this is no longer thought to be true, consider requesting calf vein assessment if you are suspicious.

* The finding of superficial venous thrombosis warrants a search for DVT. The treatment of superficial vein thrombosis is controversial and ranges from NSAIDs to compression stockings to anticoagulation. There is no consensus on treatment–the key EM issue is to rule out DVT.

* Patients who are moderate or high risk for DVT should be anticoagulated while awaiting ultrasound. If a DVT precipitant is not clear, consider calling hematology to inquire about hypercoaguable state labs to send before administering heparin.

* Many patients with DVT are optimally managed as an outpatient with daily LMWH shots. Visiting nursing services can help.

* Our interface with outside referring physicians is complex, and navigating their requests is fraught with pitfalls. If you don’t agree with their plan, the best course of action is usually an attempt to harmonize over the phone.

Wise words.

So, lots of big things were discussed today, but I’m going to focus on Dr. Judd Hollander’s talk, as it was crammed with insight on a very common problem – achieving disposition on the 8 million patients we seen annually with chest pain (this is national, not just Sinai). Of these 8 million, 3 million are sent home and so we admit 60-65% of chest pain, of which only 15% have real disease… Cardiologists hate us for this, but is there an alternative? What’s the evidence behind what we do?

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