This case describes a 29-year-old woman who presented with an acute severe anaphylactic reaction to penicillin. In addition to other medications administered in the emergency department, she received 0.1 mg intravenously of 1:10 000 epinephrine, after which she immediately developed severe chest pain. Her ECG showed ST elevations consistent with an anterior myocardial infarction, and her serum troponin level was elevated. A CT angiogram showed no signs of coronary artery disease or abnormal anatomy. This case is an example of vasospasm-induced myocardial injury and illustrates a potential danger of intravenous epinephrine use. The authors were able to identify only 2 other case reports where therapeutic doses of epinephrine have been reported to cause this phenomenon. RÉSUMÉLe cas d'une femme de 29 ans victime d'une violente réaction anaphylactique à la pénicilline est décrit. En plus des médicaments administrés dans la salle d'urgence, la patiente reçut 0,1 mg de 1:10 000 d'épinéphrine intraveineuse après quoi elle manifesta une douleur intense à la poitrine. Son ECG révéla une élévation du segment ST correspondant à un infarctus du myocarde antérieur et son taux sérique de troponine était élevé. Un angiogramme CT ne révéla aucun signe de maladie coronarienne ni d'anomalie anatomique. Ce cas est un exemple de blessure myocardique provoquée par un spasme vasculaire et illustre le danger potentiel du recours à l'épinéphrine intraveineuse. Les auteurs furent en mesure d'identifier seulement deux autres observations ayant signalé que des doses thérapeutiques d'épinéphrine avaient causé un tel phénomène.

Objectives: The authors sought to validate a clinical decision rule that young adult (younger than 40 years) chest pain patients without known cardiac disease who had either no cardiac risk factors and/or a normal electrocardiogram (ECG) are at low risk (,1%) for acute coronary syndromes (ACS) and 30-day adverse cardiovascular (CV) events. Methods: A prospective cohort study of patients 24-39 years old who received an ECG for chest pain from July 1999 to March 2002 were included. Cocaine users were excluded. Data collection was structured at presentation, hospital course was followed daily, and 30-day follow-up was obtained by telephone. The main outcome was 30-day adverse CV events (death, acute myocardial infarction, percutaneous intervention, and coronary artery bypass graft). Descriptive statistics were used. Results: Of 4,492 visits for chest pain, 1,023 met criteria. Patients were most often female (61%) and African American (73%). Ninety-eight percent were available for 30-day follow-up. The overall risks of ACS and 30-day adverse CV events were 5.4% and 2.2%, respectively, in our entire cohort. For patients with no cardiac history and no cardiac risk factors, the risk of ACS and 30-day adverse CV events was 1.8%. The risk in patients with no cardiac history and a normal ECG was 1.3%. Patients with no cardiac history, no cardiac risk factors, and a normal ECG had a risk of 1.0%. A modified clinical decision rule found that in young adult patients without a known cardiac history, either no classic cardiac risk factors or a normal ECG, and initially normal cardiac marker studies, the risk of ACS was also extremely low (0.14%) and there were no adverse CV events at 30-day follow-up (95% confidence interval = 0.1% to 0.2%). Conclusions: A modified clinical decision rule described a group of patients with a 0.14% risk of ACS that was free from 30-day adverse CV events.

OBJECTIVE Maintenance of glycemic control during and after exercise remains a major challenge for individuals with type 1 diabetes. Glycemic responses to exercise may differ by exercise type (aerobic, interval, or resistance), and the effect of activity type on glycemic control after exercise remains unclear. RESEARCH DESIGN AND METHODS The Type 1 Diabetes Exercise Initiative (T1DEXI) was a real-world study of at-home exercise. Adult participants were randomly assigned to complete six structured aerobic, interval, or resistance exercise sessions over 4 weeks. Participants self-reported study and nonstudy exercise, food intake, and insulin dosing (multiple daily injection [MDI] users) using a custom smart phone application and provided pump (pump users), heart rate, and continuous glucose monitoring data. RESULTS A total of 497 adults with type 1 diabetes (mean age ± SD 37 ± 14 years; mean HbA1c ± SD 6.6 ± 0.8% [49 ± 8.7 mmol/mol]) assigned to structured aerobic (n = 162), interval (n = 165), or resistance (n = 170) exercise were analyzed. The mean (± SD) change in glucose during assigned exercise was −18 ± 39, −14 ± 32, and −9 ± 36 mg/dL for aerobic, interval, and resistance, respectively (P < 0.001), with similar results for closed-loop, standard pump, and MDI users. Time in range 70–180 mg/dL (3.9–10.0 mmol/L) was higher during the 24 h after study exercise when compared with days without exercise (mean ± SD 76 ± 20% vs. 70 ± 23%; P < 0.001). CONCLUSIONS Adults with type 1 diabetes experienced the largest drop in glucose level with aerobic exercise, followed by interval and resistance exercise, regardless of insulin delivery modality. Even in adults with well-controlled type 1 diabetes, days with structured exercise sessions contributed to clinically meaningful improvement in glucose time in range but may have slightly increased time below range.

Objectives: The authors sought to validate a clinical decision rule that young adult (younger than 40 years) chest pain patients without known cardiac disease who had either no cardiac risk factors and/or a normal electrocardiogram (ECG) are at low risk (,1%) for acute coronary syndromes (ACS) and 30-day adverse cardiovascular (CV) events. Methods: A prospective cohort study of patients 24-39 years old who received an ECG for chest pain from July 1999 to March 2002 were included. Cocaine users were excluded. Data collection was structured at presentation, hospital course was followed daily, and 30-day follow-up was obtained by telephone. The main outcome was 30-day adverse CV events (death, acute myocardial infarction, percutaneous intervention, and coronary artery bypass graft). Descriptive statistics were used. Results: Of 4,492 visits for chest pain, 1,023 met criteria. Patients were most often female (61%) and African American (73%). Ninety-eight percent were available for 30-day follow-up. The overall risks of ACS and 30-day adverse CV events were 5.4% and 2.2%, respectively, in our entire cohort. For patients with no cardiac history and no cardiac risk factors, the risk of ACS and 30-day adverse CV events was 1.8%. The risk in patients with no cardiac history and a normal ECG was 1.3%. Patients with no cardiac history, no cardiac risk factors, and a normal ECG had a risk of 1.0%. A modified clinical decision rule found that in young adult patients without a known cardiac history, either no classic cardiac risk factors or a normal ECG, and initially normal cardiac marker studies, the risk of ACS was also extremely low (0.14%) and there were no adverse CV events at 30-day follow-up (95% confidence interval = 0.1% to 0.2%). Conclusions: A modified clinical decision rule described a group of patients with a 0.14% risk of ACS that was free from 30-day adverse CV events.

For patients admitted to the authors' institution with a potential acute coronary syndrome, there was no association between a negative evaluation for underlying coronary artery disease and overall or potentially cardiac ED visits, admissions, or cardiac resource test utilization over the year following the index visit.