Hospital Chronicles (E-Journal)
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Right Ventricular Pacing in Bradycardia Patients With Preserved Systolic Function: Results of the PACE Trial
Get PDFIn medicine, it is encouraging when research yields results consistent with our understanding of the operative mechanisms, especially when there is a direct potential impact on clinical practice. Adverse left ventricular (LV) remodeling is a complex maladaptive process involving structural, hemodynamic, histopathological, and genetics changes. The process may be multifactorial and is frequently encountered in patients after loss of myocardium (myocardial infarction), volume overload (valvular insufficiency), or pressure overload (hypertension). It involves both LV hypertrophy and dilation, and is initially an adaptive response that serves to maintain stroke volume. If persistent and progressive, the process becomes maladaptive and leads to further deterioration of LV function, LV dilation, and eventually the typical symptoms of heart failure. It is evident that substantial prolongation of the QRS complex, especially with a left bundle branch block (LBBB) pattern, results in a delayed and dyssynchronous LV contraction.This dyssynchrony may be a major contributor that can both initiate and aggravate the process of adverse remodeling... (excerpt
CYP450 2D6 Genotype and Flecainide Efficacy in the Treatment of Patients with Lone Atrial Fibrillation
Get PDFBackground: CYP2D6 has been linked to one of four phenotypes: a) ultra-rapid metabolizers (UM), with multiple gene copies; b) extensive metabolizers (EM), with a single wild type gene copy, considered normal; c) intermediate (IM) metabolizer, with decreased enzymatic activity; and d) poor metabolizers (PM) with no detectable enzymatic activity. By altering the drug dose-plasma concentration relationship, these differences may lead to severe toxicity and or therapeutic failure.Objectives: The aim of this study was to determine the correlation between CYP2D6 polymorphisms and both efficacy and magnitude of adverse reactions of flecainide, a class IC antiarrhythmic agent.Methods: Patients with Lone Atrial fibrillation (AF) were enrolled in a 2-arm prospective study: patients started on flecainide at the initial visit, then were followed up at 3 and 6 months intervals (arm 1) or exhibited AF recurrences on flecainide, defined as treatment failure (arm 2). Data about recurrence of AF, side effects, and demographics were collected. Genotyping was performed using AmpliChipTM CYP450.Results: A total of 26 lone AF patients were enrolled (12 in arm 1, and 14 in arm 2). The mean age was 47± 10.8 years and 56.2 ± 10.8 years respectively. Among the analyzed phenotypes the following distribution was found: 1/26 (3.8%) UM, 19/26 (73%) EM, 5/26 (19%) IM, 1/26 (3.8%) PM.Conclusions: In this small series of patients with lone atrial fibrillation, most patients were found to be extensive metabolizers of flecainide. There was no statistically significant correlation between the patients' genotype, and flecainide efficacy / side effects
Carotid Angioplasty and Stenting: State-of-the-Art After CREST Study
Get PDFStroke represents the third leading cause of death in the USA and the most common and disabling neurological disorder in the elderly population. A carotid stenosis is responsible for about 30% of the cases. Medical therapy with antithrombotic agents and statins has a role in reducing cardiovascular risk, but randomized trials have shown that carotid endarterectomy (CEA) is superior to medical therapy alone and is considered the gold standard treatment of a carotid stenosis. However, surgery is not without complications; the stroke and death rate at 30 days in these trials ranged from 5.8% to 7.5% in the symptomatic patients and from 2.3% to 4.3% in asymptomatic patients. In higher risk patients, like those with severe coronary artery disease, morbidity and mortality has been reported in up to 18% of patients. Carotid angioplasty and stenting (CAS) has been proposed as an alternative to surgery, and two initial randomized studies comparing CAS and CEA showed comparable results. However, after these results, numerous studies, both European and American studies, have been published with very different outcomes. Among them the most important is the American study, CREST, which demonstrated that CAS is not inferior to CEA and can now be proposed to the majority of patients suffering from a carotid stenosis. But in contrast to many other endovascular interventions, CAS represents a more challenging procedure requiring complex catheter-based skills and an extensive learning curve that explains the poor results of CAS in some published series and particularly in Europeans studies.In conclusion, after the CREST study and recent published data, CAS and CEA can be deemed equivalent for the treatment of a carotid stenosis. However, these two treatments may have some contraindications and limitations. We need appropriate patient and lesion selection, proper technique, embolic protection devices, and most importantly experienced operators. Indications for asymptomatic patients have to be discussed considering the benefit of optimal medical therapy
New Anti-Thrombotic Drugs in Acute Coronary Syndromes and Percutaneous Coronary Intervention. The Role of Prasugrel, Ticagrelor and Cangrelor
Get PDFPlatelet activation and subsequent aggregation play a dominant role in the propagation of arterial thrombosis and consequently are the key therapeutic targets in the management of acute coronary syndrome (ACS). Platelets can be activated through many pathways. Inhibition of such a pathway results only in partial attenuation of platelet function. Aspirin irreversibly blocks platelet cyclooxygenase (COX-1), inhibits thromboxane A2 formation and induces a permanent functional inhibition in platelets. As a consequence, aspirin use has been shown to safely reduce ischemic events throughout the spectrum of clinical manifestations of coronary artery disease (CAD). Therefore, aspirin is part of the standard treatment given to patients with CAD, including those undergoing percutaneous coronary intervention (PCI). Despite the inhibition of cyclooxygenase by aspirin, platelet activation can still occur through thromboxane-independent pathways, leading to aggregation of platelets and formation of thrombin. Thus, inhibition of an additional pathway of platelet activation could further reduce platelet activity. As a consequence, the antagonists of P2Y12 receptor have emerged as a major therapeutic tool in ACS. Clopidogrel, an oral P2Y12 receptor inhibitor, added to standard regimen with aspirin further reduces the short- and long-term risk of death and ischemic complications in high-risk settings, such as patients with an ACS and those undergoing PCI. However, the pharmacokinetic and pharmacodynamic effects of clopidogrel are highly variable and may be influenced by genetic polymorphisms, which translate into differential pharmacodynamics and therapeutic responses, leading to the notion of clopidogrel “nonrespondersâ€. Two newer oral adenosine diphosphate (ADP) blockers, prasugrel and ticagrelor, have been associated with less interpatient variability and a more potent platelet-aggregation response. Prasugrel was superior to clopidogrel in patients with ACS who were undergoing PCI, and ticagrelor was superior to clopidogrel in patients with ACS...(excerpt
Newer Anticoagulants for Atrial Fibrillation: the Role of Dabigatran, Rivaroxaban, Apixaban and Edoxaban / RELY, ROCKET-AF, ARISTOTLE, & ENGAGE AF TIMI 48 Studies/ Safety Issues
Get PDFAtrial fibrillation (AF) is the most common sustained cardiac arrhythmia and one of the major risk factors for ischemic stroke and thromboembolic events. Vitamin K antagonists (VKA) are considered to be the cornerstone in antithrombotic therapy for many years. Alternatively, antithrombotic drugs such as aspirin or the combination of aspirin and clopidogrel are also used, but without having proved similar or superior in efficacy compared to VKA. Moreover, therapy with VKA has complications and it is also quite demanding, as it often requires close monitoring of anticoagulation therapy. Recently, newer anticoagulants have been developed, which include direct thrombin antagonists, such as dabigatran or factor Xa inhibitors, such as rivaroxaban, apixaban and edoxaban. For each of these novel drugs large phase III clinical trials have been completed and their results have already been published, with the exception of edoxaban. These drugs are more effective compared to conventional therapies and, furthermore, they lack the need for anticoagulation monitoring. With regards to their safety profile, it has been shown to be similar to VKA. Nevertheless, some reports have recently emerged about fatal bleeding episodes after the use of dabigatran, which highlights the need for evidence based prescription of these novel drugs after thorough patient evaluation
Drainage of Post-Operative Abdominal and Pelvic Abscesses under the Guidance of Computed Tomography
Get PDFBACKGROUND: Cross sectional imaging and specifically computed tomography (CT) has become the main radiological modality of detecting post-surgical abdominal collections and abscesses. Percutaneous abscess drainage (PAD) has revolutionized the treatment of abscesses, especially of post-surgical abdominal abscesses over the last 25 years; repeat laparotomy is a rare event due to the fact that the success rate of PAD is very high (90-95%) and complications are few (0-10%).OBJECTIVE: The aim of the study is to present our experience in the department of computed tomography of the percutaneous drainage of post-operative abdominal and pelvic abscesses.PATIENTS AND METHODS: During the last two and a half years, 93 post-operative patients were referred to the CT department for drainage of a post-surgical abscess in the abdomen or pelvis at 9-21 days post-operatively due to persistent fever. A total of 95 abscesses were drained; 84 were located in the abdomen and 11 in the pelvis. Abscess diameters ranged between 2 and 12 cm. A percutaneous drainage technique under CT-guidance was employed in all patients; 98 catheters were placed with use of the Seldinger technique. A transgluteal paracoccygeal approach was adopted in 11 patients. Aspiration of an intra-loop abscess was performed in 1 patient. The tilted gantry technique was utilized in 2 cases.RESULTS: Eighty-nine (95.7%) patients were successfully treated. In 4 (4.3%) patients the abscesses were partially drained, patients were stabilized and subsequently treated via laparotomy. Complications included inflammation of the skin at the entry site in 4 patients, pneumothorax in 1 patient, and displacement of the catheter in 12 patients, one involving catheter migration into the duodenum. Major complications did not occur.CONCLUSION: Percutaneous drainage of post-operative abdominal and pelvic abscesses was a safe and effective method of abscess management in our series with a 95.7% success rate and absent major complications. It is currently a widely used procedure, eliminating the need for repeat laparotomy in the majority of patients. Proper catheter management is essential for the successful outcome
“Broken Heart Syndromeâ€: What Women Should Know
Get PDFThe Takotsubo syndrome or apical ballooning, also known as “broken heart syndrome†(BHS) among a variety of suggested names, was first described by Sato et al in the Japanese population approximately 20 years ago. Since then, it has been increasingly recognized in other countries and in 2006 it was classified as a type of stress cardiomyopathy among acquired cardiomyopathies. The prevalence of the BHS is estimated to be 1-2% of patients presenting with an acute coronary syndrome but higher rates have been reported lately, due to a wider recognition of the syndrome. One of the hallmarks of the BHS is a strict predilection for postmenopausal women (over 90% in most series), whereas men account for less than 10% of cases. It has also been reported that among BHS patients, 43% had a preceding acute medical condition and 27% had a severe emotional or physical stressor associated with a “fight or flight†hypersympathetic response... (excerpt
Totally Occlusive Diffuse In-stent Restenosis in Saphenous Vein Graft to Right Coronary Artery and Acute Coronary Syndrome
Get PDFA 78-year-old gentleman presented with Canadian Cardiological Society (CCS) class III angina and had been getting excruciating substernal pain while walking 50 to 100 m on the flat over the last 15 days despite optimal medical therapy. From his past medical history the patient underwent CABG in 1997 (LIMA to LAD and SVG to dominant RCA); in 2006 he had an angioplasty done in his SVG and stents were implanted (no medical data regarding the angioplasty were found). Cardiac enzymes and troponin were negative; a mild increase of creatinine was noted on admission. The echocardiogram revealed severe basal inferior wall hypokinesia with overall reasonably preserved left ventricular and right ventricular systolic function... (excerpt
Current Concepts on Revascularization Strategy in Patients with Diabetes Mellitus
Get PDFPatients with diabetes mellitus have more advanced coronary artery disease (CAD) eith greater plaque burden, longer lesions, smaller, more diffusely diseased vessels. On the other hand, approximately 25% undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) have diabetes. Regardless of the type of revascularization, diabetic patients have worse prognosis compared to patients without diabetes. With regards to PCI, diabetic patients have a higher restenosis rate and are at greater risk for myocardial infarction and stent thrombosis than patients without diabetes... (excerpt
Atherosclerosis: an Athero-Thrombo-Inflammatory Disease
Get PDFClassical risk factors for the development of atherosclerosis include hypercholesterolemia, hypertension, smoking, and diabetes. When the atheromatous plaque erodes or ruptures, local thrombosis develops which leads to partial or complete vessel occlusion with its attendant potentially catastrophic consequences. Thus, the term athero-thrombotic disease has been adopted. However, inflammation is also a major contributor to the initiation and evolution of this process and has not been adequately addressed. The concept that atherosclerosis is an inflammatory disease has caused a paradigm shift in our understanding of its pathogenesis. Recent convincing evidence has accumulated that inflammation plays a fundamental role in atherothrombosis and the associated risk may be equal to that of hyperlipidemia. Based on this concept, new biomarkers and novel anti-inflammatory and immune therapies are being currently tested for managing atherosclerotic cardiovascular disease