Hospital Chronicles (E-Journal)
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The End of the Digoxin Era?
Full text linkDigoxin is one of the oldest of cardiovascular drugs which is still frequently used, both in patients with atrial fibrillation (AF) and patients with heart failure with or without AF. The use of digoxin preceded the era of evidence based medicine. However, over the recent past, there has been growing evidence disputing and challenging the safety and efficacy of digoxin, while evidence has accumulated that a plethora of other therapies for both heart failure and atrial tachyarrhythmias has proven more effective and safe. Nevertheless, digoxin still retains its role, albeit limited, in the current era, but most recent evidence has cast significant doubts about its safety. Thus, its role remains controversial and the drug should be reserved for specific patients and clinical scenarios, with careful monitoring of its serum concentration due to its narrow therapeutic and toxic ranges, maintaining it <0.8 ng/mL, with additional monitoring of serum electrolytes and renal function to avoid potential confounders that may enhance the proarrhythmic risk and susceptibility to digoxin toxicity
Advances in Cardiopulmonary Resuscitation: Hypothermia versus Normothermia in Survivors of Out-of-Hospital Cardiac Arrest
Full text linkDespite high levels of public awareness, the widespread use of automatic external defibrillators and the ongoing education of doctors in advanced life support seminars, the percentage of victims who arrive at the hospital after out-of-hospital cardiac arrest (OHCA) is small. Of those who reach the hospital, the main cause of death in two thirds of the cases is persistent neurologic disability. The only therapy that has so far seemed to positively affect the neurological outcome of patients after cardiac arrest is mild therapeutic hypothermia (MTH). However, the application of MTH is also known to be associated with a number of potential adverse effects, and recent trials report on an increasing rate of stent thrombosis. If the results are confirmed, safe levels of temperature regulation would need to be defined. Recently, a study was published that takes a critical approach to MTH. Hypothermia was compared to targeted temperature management near normothermia. After the end of the study period, there was no statistically significant difference regarding the survival to discharge and the neurological prognosis at 180 days. The authors stress that in both groups the temperature was actively controlled to avoid temperatures over 37 degrees Celsius. There followed few more publications with similar findings. The most important message from these trial is that even if the aggressive regulation of temperature with the form of hypothermia may seem unjustified, this does not mean that fever should be left untreated. Normothermia is a goal that can be achieved rather easily and can also save the lives of many patients
Cardiology News / Recent Literature Review / Third Quarter 2015
Full text linkTCT Meeting 2015: San Francisco, 11-15/10/2015HCS Congress: Thessaloniki, 29-31/10/2015AHA Scientific Sessions: Orlando, 7-11/11/2015Boston AF Symposium: Orlando, 14-16/1/2016ACC 65th Annual Session: Chicago, 2-4/4/2016HRS 37th Annual Meeting: San Francisco, 4-7/5/16CardioStim/Europace: Nice, 8-11/6/2016Euro PCR: Paris, 17-20/5/2016ESC Meeting: Rome, 27-31/8/2016Sustained chronic obesity results in chronic stretch, diffuse interstitial fibrosis, conduction abnormalities, and increased vulnerability to AFIn an animal study, 10 chronically obese sheep, compared with 10 age-matched controls, demonstrated greater total body fat, left atrial (LA) volume, LA pressure, and pulmonary artery pressures, reduced atrial conduction velocity with increased conduction heterogeneity, increased fractionated electrograms, decreased posterior LA voltage, and increased voltage heterogeneity (all p<0.001), with no change in the effective refractory period (ERP) or ERP heterogeneity. Obesity was associated with more episodes (p= 0.02), prolongation (p= 0.01), and greater cumulative duration (p= 0.02) of atrial fibrillation (AF). Epicardial fat infiltrated the posterior LA in the obese group (p< 0.001), consistent with reduced endocardial voltage in this region. Atrial fibrosis (p= 0.03) and atrial transforming growth factor (TGF)-β1 protein (p= 0.002) were increased in the obese group. The authors concluded that obesity results in global biatrial endocardial remodeling, and increased propensity for AF (Mahajan R et al, J Am Coll Cardiol 2015;66:1-11).An Increased Percentage of PVCs on 24-h Holter Monitoring Confers a Decrease in LVEF, Increased Incident CHF, and Increased Mortality: PVCs might be an Important Cause of Occult or “Idiopathic†Cardiomyopathy and an Important Determinant of Incident CHF Among Those with Other Established CHF Risk FactorsAmong 1,139 Cardiovascular Health Study (CHS) participants, with a normal LVEF and no history of CHF, randomly assigned to 24-h Holter monitoring, those in the upper quartile vs the lowest quartile of PVC frequency had a 3-fold greater odds of a 5-year decrease in LVEF (odds ratio [OR]: 3.10; p= 0.005), a 48% increased risk of incident CHF (HR: 1.48; p= 0.02), and a 31% increased risk of death (HR: 1.31; p = 0.01) during a median follow-up of >13 years. The specificity for the 15-year risk of CHF exceeded 90% when PVCs included at least 0.7% of ventricular beats. The population-level risk for incident CHF attributed to PVCs was 8.1%. The authors concluded that in a population-based sample, a higher frequency of PVCs was associated with a decrease in LVEF, an increase in incident CHF, and increased mortality (Dukes JW et al, J Am Coll Cardiol 2015;66:101-109)... (excerpt
Left Idiopathic Ventricular Tachycardia Amenable to Radiofrequency Ablation
Full text linkAn 18-year-old gentleman with a 5-year-long history of palpitations was referred for radiofrequency ablation of a wide-QRS complex tachycardia. He admitted having 2-3 tachycardia episodes per year, which had recently increased in frequency despite therapy with a beta blocker, recently combined with the antiarrhythmic medication flecainide (100 mg bid). The morphology of the tachycardia on the 12-lead electrocardiogram indicated a right bundle branch block with a left axis deviation at a cycle length of 290 ms (207 bpm) (Fig. 1A). Cardiac work-up revealed a normal heart anatomy by echocardiography, while a treadmill test was normal with no provokable arrhythmia... (excerpt
Resveratrol and Cancer
Full text linkResveratrol is a stilbene substance, belonging to the superfamily of phytoalexins, which are compounds synthesized by plants when stress occurs, usually an infection. It is abundant in red wine, red grapes, blueberries, peanuts and pistachios. Resveratrol induces p53-dependent apoptosis. A novel resveratrol analogue, HS-1793, has recently been demonstrated to inhibit vascular endothelial growth factor (VEGF) in human prostate cancer cells. Pterostilbene, an analog of resveratrol, has been demonstrated to exert both autophagy and apoptosis in human bladder and breast cancer cell lines. It has also been found to cause accumulation of autophagic vacuoles as well as promote cell death via a mechanism involving lysosomal membrane permeabilization in human melanoma, colon, lung and breast cancer cell lines. Identification of a receptor site for resveratrol in cancer cells, supports the potential of this compound as a therapeutic agent. The receptor could also serve as a vehicle for studies of future resveratrol analogues. Resveratrol has also been documented to overcome chemo-resistance by inhibiting NF-κB and STAT3 pathway. Resveratrol has shown much promise in preclinical trials and because of its good safety profile it may be an ideal chemo-preventive and chemotherapeutic agent
Tuberculosis Notifications and Mortality in Greece During the Period of 2003 to 2012
No full textDear Editor,According to the latest World Health Organization report the rate of new tuberculosis (TB) cases has been falling worldwide for over a decade.1 However, TB continues to be a major global public health problem (in 2013, an estimated 9.0 million people developed TB and 1.5 million died from the disease) and surveillance is an essential part of any TB control plan.1 There is evidence that financial crisis can influence tuberculosis incidence and mortality.2 Greece is considered a low incidence country for TB. However, since the final quarter of 2008, Greece has entered the most serious financial downturn in the country’s modern history and this has posed major threats to the health of the population.3 Rates of several communicable diseases have also increased.4 Specifically, an HIV outbreak among intravenous drug users occurred in 2011 and worsened in 2012, increasing the total number of HIV infections reported in Greece from 530 in 2010 to 826 in 2011 and 1,001 in 2012.5 Furthermore, many previously rare or absent infections have also now been reported, including malaria in 2011 and 2012 (previously absent since 1974),West Nile virus in 2010-2012 (never previously reported) and rabies in 2012 (previously absent since 1987).4 In view of this financial crisis we sought to evaluate the potential impact of the financial crisis on the notification rate and the mortality due to TB among the whole Greek population... (excerpt
A Case of an Unusual Relapse of Multiple Myeloma
Full text linkExtramedullary relapse constitutes an uncommon manifestation of multiple myeloma, but central nervous system involvement as the only manifestation of relapse appears even less common. A 50-year-old man with a history of multiple myeloma achieved complete remission after autologous hematopoietic stem cell transplantation. Fifteen months later, he presented with central nervous relapse with no signs of systemic disease
A Novel Variant Translocation t(8;16;21)(q22;q24;q22) in Acute Myeloid Leukemia Expressing both Myeloid and Lymphoid Markers
Full text linkWe present a novel, rare but recurrent variant three way translocation of t(8;21), t(8;16;21)(q22;q24;q22), as a primary cytogenetic abnormality, resulting in AML1/ETO fusion gene in order to clarify the clinical features and outcome of these patients. According to WHO 2008 our case is described as AML expressing both myeloid and lymphoid markers, although according to EGIL scoring system is described as Biphenotypic Acute Leukemia. Our patient was considered as a high risk patient based on his single blast population with evidence of simultaneous myeloid and B-lymphoid differentiation, the unknown implications of t(8;16;21) and the discovery of minimal residual disease shortly after the last chemotherapy cycle. Eventually, he displayed an excellent outcome after allogeneic BMT and he is in an excellent condition 4 years post diagnosis. This case could be advisable for prognostic and therapeutic purposes.Â
Right Ventricular Septal Pacing: In Lieu of Biventricular Pacing for Cardiac Resynchronization in a Patient With Right Bundle Branch Block?
Full text linkA 71-year-old male with ischemic cardiomyopathy, severe systolic left ventricular dysfunction and symptomatic heart failure was not considered a good candidate for implantation of a biventricular pacing system to effect cardiac resynchronization due to underlying right bundle branch block (RBBB). He received instead a dual-chamber implantable cardioverter defibrillation with the ventricular lead placed at an alternate site position at the high right ventricular septum. This resulted in significant narrowing of the QRS duration (resynchronization) with a good clinical response over short-term. The case illustrates a possible alternative approach to biventricular pacing for cardiac resynchronization in patients with RBBB