Hospital Chronicles (E-Journal)
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Drug-Induced Proarrhythmia: QT Interval Prolongation and Torsades de Pointes
Get PDFDrug-induced torsades de pointes (TdP), a life-threatening polymorphic ventricular tachycardia associated with prolongation of the QT interval, has been the main safety reason for the withdrawal of non-cardiac agents from clinical use over the last decade. This complication is commonly referred to as drug-induced proarrhythmia. The present review highlights on the mechanisms underlying the drug-induced QT interval prolongation and TdP as well as on the identification of easily recognized risk factors that predispose to this potentially life-threatening condition
Therapeutic Approach to Advanced Pancreatic Carcinoma
Get PDFPancreatic carcinoma, a chemoresistant disease, still remains a therapeutic challenge in oncology. A variety of cytotoxic agents have been tried with promising or disappointing results. Gemcitabine as a single agent or combined chemotherapy is the mainstay therapeutic approach in locally advanced or metastatic disease. Newer agents, such as tyrosine kinase inhibitors and monoclonal antibodies (bevacizumab, erbitux) are widely used nowadays in modern therapeutic algorithms with promising results. Key words: pancreatic carcinoma; gemcitabine; chemotherapy; monoclonal antibodies; kinase inhibitor
Adjunctive Antiplatelet Treatment in Primary Percutaneous Coronary Intervention
Get PDFBackground: Despite significant advances in the management of coronary heart disease, myocardial infarction is still associated with high mortality. Thienopyridines and glycoprotein IIb/IIIa inhibitors have been used extensively in the management of ST segment elevation myocardial infarction. Objective: This article discusses the evidence from clinical trials and registries concerning the benefits of thienopyridines, reviews the results of published multicenter, randomized controlled trials of the efficacy and safety of platelet GPIIb/IIIa inhibitors in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention (PCI) and presents the recent guidelines.Methods: Data for this review were identified by broad searches of MEDLINE, Current Contents and references from relevant articles (1980-2011); numerous articles were identified through searches of the extensive files of the authors and selected based on their importance, oppurtunity for further reading and up to date information. Search terms included thienopyridines, platelet aggregation inhibitors, percutaneous coronary intervention, antiplatelet therapy, ST elevation myocardial infarction (STEMI), primary percutaneous coronary intervention. Only English language papers were reviewed. No restrictions were set on the type of papers.Results: Clopidogrel is the most commonly used thienopyridine in patients undergoing primary PCI. Recently new inhibitors of P2Y12 receptors, like prasugrel and ticagrelor, have become available, which have a more potent and rapid onset of action, with similar safety profile, which is specifically targeted to the subgroup of primary PCI. On the other hand, the platelet glycoprotein IIb/IIIa inhibitors have aided and abetted medical management of acute coronary syndromes and proved an important adjunctive therapy in percutaneous coronary interventions. Platelet glycoprotein IIb/IIIa inhibitors, although not recommended for routine therapy, have an important role at the time of primary PCI, particularly in high-risk subgroups, like the diabetics and those with a heavy thrombotic burden.Conclusion: Clopidogrel remains the most used thienopyridine together with aspirin in patients undergoing primary PCI but there are currently available new inhibitors of P2Y12 receptors, like prasugrel and ticagrelor, which have a more potent and rapid onset of action, with similar safety profile. Glycoprotein IIb/IIIa antagonists, although not recommended for routine therapy, can be of use at the time of primary PCI, particularly in high-risk subgroups
Peculiar Electrocardiographic Feature Accurately Localizing an Unusual Case of Permanent Junctional Reciprocating Tachycardia
No full textPermanent junctional reciprocating tachycardia (PJRT) is an uncommon form of supraventricular tachycardia due to an accessory pathway with slow retrograde conduction that is mostly localized in the posteroseptal area. The standard ECG shows long RP tachycardia with negative P waves in the inferior leads and positive P waves in leads I and aVL. We report a case of PJRT in a 31-year-old lady with incessant long RP tachycardia displaying negative P waves not only in the inferior leads but also in leads I and aVL. The accessory pathway was localized in the left posteroseptal region and managed successfully with radiofrequency catheter ablation
Phantom Stent Thrombosis
Get PDFInitial visualization of only the left circumflex coronary artery during coronary angiography in a 71-year-old patient with prior stenting of the left anterior descending (LAD) coronary artery would have led to an erroneous conclusion of a thrombosed stent and occluded coronary artery with its consequent management problems, before it was disclosed that the LAD originated from a separate ostium
Tissue Molecular Techniques in Lymphoproliferative Disorders: Contribution to Diagnosis, Prognosis, Therapy and Follow up. Bridging Molecular Pathology with Clinical Practice
Get PDFMolecular data are an essential component in the study of neoplasias. The important and incumbent role of molecular pathology in clinical practice is evident in the last classification of the World Health Organization (WHO) in 2008 for the tumors of the hematopoietic and lymphatic tissues, where incorporated are all the new molecular data and entities defined by genetic criteria. It is now recognized that a genetic abnormality can be considered diagnostic for an entity. At the same time the diagnostic approach of lymphoproliferative disorders is multifactorial; morphological, immunohistochemical and genetic characteristics, along with clinical data, are required for the diagnosis.In the hematopathology laboratory, the molecular techniques used in every day practice regarding tissues are polymerase chain reaction (PCR) and in situ hybridization (ISH) using either a fluorescence chromogen (FISH) or plain chromogenic in situ hybridization (CISH). The usefulness of these molecular techniques in lymphoproliferative disorders is to document B- or T- cell clonality, including diagnosis of lymphoma, differential diagnosis between a reactive lymphadenopathy and lymphoma, staging, follow up, and detection of early stages of a lymphoma, and to detect genetic abnormalities, numerical or structural, diagnosis of certain lymphoma subtypes encompassing distinction of subtypes within the same entity with different biological behavior, prognostic indices, and indices of response to certain therapeutic regimens
A Case of Asymptomatic Brugada Electrocardiographic Pattern Incidentally Unmasked During the Recovery Phase of an Exercise Stress Test
Get PDFThe interest about Brugada syndrome, an inherited channelopathy associated with sudden cardiac death in individuals without structural heart disease, is exponentially increasing lately. Similarly to chameleon, the electrocardiographic (ECG) signal of the disease fluctuates over time, it is often concealed, and may be unmasked under certain conditions. Recently, emergence of the characteristic ST-segment elevation during exercise stress test (EST) has been reported, probably resulting from an alteration of the autonomic tone in the different stages of exercise. We present the case of a 43-year-old, otherwise healthy male with an asymptomatic Brugada ECG pattern incidentally unmasked during the recovery phase of an EST
"Real World" Adhoc Percutaneous Coronary Interventions With Use of Sirolimus Eluting Stents: A Single Operator Experience and Long-term Follow-up
Get PDFBACKGROUND: Drug eluting stents (DES) have ushered in a new era in percutaneous coronary intervention (PCI), curtailing significantly the restenosis rates compared with bare metal stents (BMS). However, their use has been plagued with the late stent thrombosis phenomenon. OBJECTIVE: During a 5-year period, sirolimus-eluting stents (SES) were employed in 260 patients among 675 consecutive patients submitted to PCI by a single-operator with a uniform technique. The objective of this study was to assess the clinical and angiographic results and to report the incidence of stent thrombosis and the long-term outcome in these patients. METHODS & PATIENTS: A consistent single-operator approach with 0.5 mm stent oversizing and high pressure (>12-18 bar) stent deployment was adopted, routinely combined with long-term dual antiplatelet therapy for at least a two-year period post-implantation. The study included 213 men and 47 women, aged 64+12 years, who presented with stable angina and/or positive exercise test (n=54), unstable coronary syndrome (n=125), or acute myocardial infarction (MI) (n=81). The dilated vessel was the left main stem (n=4), left anterior descending and/or its diagonal branch (n=178), the right coronary (n=103), the circumflex and/or its obtuse marginal branch (n=89), the ramus branch (n=10), a saphenous vein (n=11) or arterial (n=2) graft. Three groups were compared: 104 (40%) patients receiving SES alone (Group A), 122 patients receiving SES plus other DES (Group B), and 34 patients receiving SES plus BMS (Group C). RESULTS: The majority (93.8%) of PCI procedures were performed adhoc during the same session of coronary angiography. All 3 groups had similar demographics, mean age (62-66 years), initial stenosis (88-89%) and mean ejection fraction (45-55%). Procedural success (99-100%) and residual stenosis (<0-10%) were also similar. Multivessel PCI and stenting was performed in 120 (46.3%) patients and multilesion PCI in the majority (89.2%) in this cohort. Overall, a mean number of 1.6+0.7 vessels and 3.1+1.6 (range, 1-9) lesions were dilated. A median of 2 stents (mean of 2.6+1.3 stents) were implanted in 260 patients; group A (patients receiving SES alone) received the least number of stents (1.7+0.7). There was one occurrence of subacute stent thrombosis in group C (0.4%). All patients received combined therapy with aspirin and clopidogrel, the latter administered for >24 months. Over 16.3+14.7 months of follow-up, survival free of events (death, MI, stroke, repeat revascularization and restenosis) was excellent at 98%, 96%, and 97% at 12 months and 95%, 90% and 97% at 24 months for groups A, B and C respectively; long-rank (Mantel-Cox) test p value= 0.27. Clinical restenosis rates were low in all 3 groups (0% vs 1.6% vs 5.9%) (p=NS). Possible very late stent thrombosis could be suspected in 1 patient (group B) who had sudden cardiac death at 32 months after the procedure. CONCLUSION: In a consecutive series of 260 patients receiving SES and/or other stents, a uniform single-operator approach with 0.5 mm stent oversizing and high-pressure (>12-18 bar) deployment routinely combined with long-term dual antiplatelet therapy resulted in high procedural success (>99%), very low rate of subacute (0.4%) and late stent thrombosis (0.4%), very low clinical restenosis rates (0-5.9%) and overall excellent survival free of cardiovascular events at 1 and 2 years
The New Guidelines for Cardiopulmonary Resuscitation
Get PDFIn the new (2010) cardiopulmonary resuscitation (CPR) guidelines, and for adult victims of out-of-hospital cardiac arrest, the four pillars of resuscitation are the immediate recognition of cardiac arrest and activation of the emergency response system, early performance of high quality bystander CPR simplified to include chest compressions alone (cardiocerebral resuscitation-CCR, which seems comparable to conventional CPR) and early defibrillation. To effect the latter, integration of automatic external defibrillators (AEDs) into a system of emergency care is critical in the Chain of Survival in public places outside the hospitals. Organized post– cardiac arrest care is the new fifth link in the chain of survival, with an emphasis on multidisciplinary programs that focus on optimizing hemodynamic, neurologic, and metabolic function, including therapeutic hypothermia and early primary percutaneous intervention in cardiac arrest victims suffering from an acute myocardial infarction, which may improve survival to hospital discharge for those who achieve recovery of spontaneous circulation following cardiac arrest. Key Words: cardiac arrest; cardiopulmonary resuscitation; resuscitation guidelines; automatic external defibrillators; acute coronary syndromes; acute myocardial infarction; ventricular fibrillatio
Sleep Apnea Syndrome: More Than Benign Snoring. Implications for the Cardiovascular System
Get PDFSleep disordered breathing is a rather common problem in the general population. Apnea during sleep can be divided into three types: central, obstructive and mixed. In central apneas there is lack of both airflow and respiratory efforts. It is recognized by its waxing-waning pattern of respiration called Cheyne- Stokes respiration. Central sleep apnea is most commonly seen in patients with heart failure and its prevalence among this group of patients is estimated to be as high as 30-40%. Obstructive sleep apnea occurs approximately in 5-15% of the general population. It usually affects middle-aged men with an increased body-mass index and a large neck circumference. It is characterized by repetitive complete or partial obstruction of the upper airway during sleep, which is followed by increasing and ineffective respiratory efforts. Sleep fragmentation in patients with sleep apnea syndrome results in sleepiness, fatigue, morning headaches and depression. This daytime presentation together with loud snoring, choking and pauses of respiration during sleep should make primary care physicians suspicious of sleep disordered breathing. The best method used for the diagnosis of sleep apnea syndrome is overnight polysomnography. The pathophysiologic mechanisms, which take place in sleep apnea, include sympathetic activation, hypercoagulability, inflammation and production of pro-inflammatory cytokines, endothelial dysfunction, oxidative stress and metabolic dysfunction. All these mechanisms are associated with the development and progression of cardiovascular disease. There is a strong linkage between sleep apnea and hypertension, systolic and diastolic dysfunction of the left ventricle, congestive heart failure, coronary artery disease, cardiac arrhythmias, stroke and pulmonary disease. Given the increased morbidity and mortality of patients with sleep apnea, an effective treatment must be started as soon as possible after the diagnosis is made. Currently, nasal continuous positive airway pressure constitutes first line therapy. This therapy improves both quality of sleep and cardiovascular and general outcomes