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DNR patient with STEMI = To PCI or not?


Comprehensive guidelines that cover a variety of issues with diagnostic and therapeutic challenges do not extend to the management of the acute MI patient with STEMI who is a potential candidate for treatment with PCI and is labeled "do not resuscitate".  Opinions vary as to whether we should accept this type of patient for acute intervention. What is the consensus? Should we evaluate such patients on a case-by-case basis? Do you have a strategy for situations like this? Is there a "safe harbor" for management? Will this problem become more commonplace as patients elect advanced planning to a greater extent?  What are your thoughts?

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A truly bizarre question in my mind. By the usual definition of DNR, the patient has declined resuscitatin in the event of cardiac or respiratory ARREST. Nothing more. Nothing less. DNR is not synonymous with "comfort measures only", or with "no fancy therapies" Too many people witness medicolegal tragicomedies like the Nancy Schiavo case, sign DNR forms, and are then get treatment far different than what they signed for. IN my experience,many poeple sign DNR fomrs menaing that they don't want decades of support in a vegetative state, and are shocked when I tell them that the form they signed actually precludes even short term mechanical ventilation.
Posted by auersperg, Sep 11, 2009 Publié le auersperg, 09.11.2009

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About Dr Seth Bilazarian
Seth Bilazarian MD has been a Clinical and Interventional Cardiologist at Pentucket Medical Associates in Massachusetts since 1993. He is board certified in Internal Medicine, Cardiovascular Medicine, Nuclear Cardiology, Vascular Ultrasound, Interventional Cardiology, and Vascular and Endovascular Medicine.

Dr Bilazarian performs coronary and peripheral interventions at Lahey Clinic and Massachusetts General Hospital. He has been an investigator in the interventional laboratory for new devices including drug-eluting stents, distal protection devices, imaging devices (OCT and InfraRed), and anticoagulant pharmacotherapy.

Dr Bilazarian is an active participant in clinical trials in congestive heart failure, hypertension, coronary disease prevention, prediabetes management, anemia, atrial fibrillation, and anticoagulation/antiplatelet therapies in the outpatient setting. He has authored numerous papers and book chapters in clinical cardiology. He was appointed as a physician advisor to the circulatory device panel of the FDA in 2008.
About this blog
My intent is to create a forum for dialogue on issues pertinent to private practice cardiology around topics such as:

  • Integration of new data and guidelines on inpatient and outpatient practice in clinical and interventional cardiology
  • Practice approaches to the extra clinical issues in dealing with managed care insurers
  • Strategies for navigating the restrictions of pharmacy benefits managers (PBMs) on pharmacologic therapies for our patients
  • Experiences with restrictions on testing and imaging
The video blog (VLOG) will provide an opportunity to share broadly different approaches to the common conundrums we face in caring for patients. My hope is that this forum will provide useful data points for practice outside of tertiary and academic centers and a look inside community hospitals and physician’s practice patterns in the office, starting with mine.