Hospital Chronicles (E-Journal)
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The Influences of Nitric Oxide, Epinephrine, and Dopamine on Vascular Tone: Dose-Response Modeling and Simulations
Full text linkBackground: Sodium nitroprusside has successfully been an excellent choice when considering a decrease in systemic vascular resistance in the critical care setting. However, reflex tachycardia and ventilation-perfusion mismatch are possible side effects of this agent. To maintain cardiac output, cerebral perfusion pressure, and concurrently drop systemic vascular resistance (SVR), low-dose epinephrine or dopamine are viable options. The aim of this paper is to conduct dose-response simulations to identify the equivalent dopamine, epinephrine, and nitroprusside infusion doses to decrease the systemic vascular resistance by 20% and by 40% from baseline resting values.Methods: Three studies were identified in the literature wich reported epinephrine, dopamine, and sodium nitroprusside infusion doses with corresponding systemic vascular resistance responses. Infusion doses were normalized to mcg/kg/min and SVR values were normalized and scaled to the percent decrease (%SVR) in SVR from baseline resting values. The original published studies were mathematically modeled and the Hill equation parameters used for further dose-response simulations of a virtual population. One-hundred patients were simulated various doses resulting in corresponding %SVR responses for each of the three drugs.Results: Equivalent infusion doses achieving an approximate 20-25% decrease in SVR from baseline, were identified for epinephrine, dopamine, and sodium nitroprusside. Moreover, equivalent infusion doses were identified for epinephrine and nitroprusside to decrease the SVR by 40% from baseline.Conclusion: Even though sodium nitroprusside is traditionally used to decrease SVR, low doses of dopamine or epinephrine are viable alternatives to patients with contraindications to nitroprusside infusions or who will require prolonged infusions to avoid toxicity. The multiple comparisons procedure-modeling approach is an excellent methodology for dose-finding exercises and has enabled identification of equivalent pharmacodynamic responses for epinephrine, dopamine, and sodium nitroprusside through mathematic simulations
Cardiology News / Recent Literature Review / Last Quarter 2015
Full text linkBoston 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, 27-31/8/2016Targeting Ablation to the Distal Segment of the Main Renal Artery and Post-Bifurcation Branches May Optimize Renal DenervationInsufficient procedural efficacy has been proposed to explain nonresponse to renal denervation (RDN). The impact of different patterns of lesion placements on the efficacy and consistency of catheter-based radiofrequency (RF) RDN was examined in pigs. Increasing the number of RF lesions (4, 8, and 12) in the main renal artery was not sufficient, but targeted treatment of the renal artery branches or distal segment of the main renal artery resulted in markedly less variability of response and significantly greater reduction of both norepinephrine (NE) and axon density than conventional treatment of only the main renal artery. Combination treatment (main artery plus branches) produced the greatest change in renal NE and axon density with the least heterogeneity. The changes lasted through 28 days post-treatment (Mahfoud F et al, J Am Coll Cardiol 2015;66:1766-1775).High Levels of Cardiorespiratory Fitness in Midlife Confer Lower Mortality, Use of Health Care Resources, and Health Care Costs Later in LifeAmong 19,571 healthy individuals who underwent cardiorespiratory fitness assessment at a mean age of 49 years, over 126,388 person-years of follow-up, average annual health care costs were significantly lower for participants aged >65 years with high than low midlife fitness in both men and women. Average annual health care costs in later life were incrementally lower per MET achieved in midlife in men and women. The authors concluded that higher cardiorespiratory fitness in middle age is strongly associated with lower health care costs at an average of 22 years later in life, independent of cardiovascular risk factors (Bachmann JM et al, J Am Coll Cardiol 2015;66:1876-1885).Very Late Thrombosis of Bioresorbable Coronary Scaffolds Despite Antiplatelet Therapy, Possibly Related to Scaffold Discontinuity and Restenosis, Implies an Extended Period of Vulnerability to Ischemic EventsFour patients presented with very late scaffold thrombosis (VLScT) at 44, 19 (2 cases), and 21 months, after implantation of an Absorb Bioresorbable Vascular Scaffold. At the time of VLScT, all patients were taking low-dose aspirin, and 2 patients were also taking prasugrel. Optical coherence tomography (OCT) showed malapposed scaffold struts surrounded by thrombus in 7.1%, 9.0%, and 8.9% of struts in 3 cases. Scaffold discontinuity with struts in the lumen center was the cause of malapposition in 2 cases. Uncovered scaffold struts with superimposed thrombus were the predominant findings in 1 case. OCT percent area stenosis at the time of VLScT was high in 2 cases (71-75%) without evidence of excessive neointimal hyperplasia. Thrombus aspirate analysis showed persistence of intracoronary polymer fragments in 1 case (Räber L et al, J Am Coll Cardiol 2015;66:1901-1914)... (excerpt
Febrile Shock is not Always Septic
No full textA 47-year-old woman with a history of poorly treated tachyarrhythmia was admitted to the intensive care unit (ICU) with hemodynamic instability of uncertain etiology. Two days earlier the patient presented at the Emergency Department of a rural hospital with febrile diarrhea of recent onset. The ECG showed rapid atrial fibrillation. She was initially admitted to the Internal Medicine ward and within 24 hours she developed high fever with signs of circulatory collapse, acute pulmonary edema and was subsequently intubated with a working diagnosis of septic shock. At the time of the ICU admission, the patient had already developed multi-organ dysfunction with renal insufficiency and liver failure. Right heart catheterization revealed a profile of high cardiac output with very low systemic vascular resistance. A high index of clinical suspicion led to the diagnosis of thyroid storm. Despite prompt initiation of the appropriate therapy and rigorous supportive care the patient died 9 days later due to disseminated intravascular coagulation and acute liver failure
Cardiology News / Recent Literature Review / Second Quarter 2016
Full text linkESC Meeting: Rome, 27-31/8/2016HCS Panhellenic Congress: Athens, 20-22/10/2016TCT Conference: Washington, DC, 29/10-2/11/2016AHA Scientific Sessions: New Orleans, 12-16/11/2016AF Symposium: Orlando, 12-14/1/2017ACC.17: Washington, DC, 17-19/3/2017HONEST Study: Morning Home Blood Pressure (BP) May be Superior to Clinic BP as a Predictor of Coronary Events and Stroke in Patients With HypertensionIn 21,591 hypertensive patients (mean age ~65 years), having 127 stroke and 121 CAD events over a mean follow-up of 2 years, the incidence of stroke events was significantly higher in patients with morning home systolic blood pressure (HSBP) ≥145 mmHg compared with <125 mmHg (hazard ratio -HR ~6.0), and in patients with clinic systolic blood pressure (CSBP) ≥150 mmHg compared with <130 mmHg (HR 5.82); morning HSBP predicted stroke events similarly to CSBP. Incidence of CAD events was significantly higher in patients with morning HSBP ≥145 mmHg compared with <125 mmHg (HR 6.24) and in patients with CSBP ≥160 mmHg compared with <130 mmHg (HR 3.51). Thus, compared with morning HSBP predicted CAD events more strongly than CSBP (Kario K et al, J Am Coll Cardiol 2016;67:1519-1527).A 1-h Combination Algorithm Allows Fast Rule-Out/ Rule-In of Major Adverse Cardiac Events (MACE): In Patients with Chest Pain Presenting to Emergency Department (ED), Combining hs-cTnT Levels on Arrival and 1 h Later With the Patient History and ECG More Effectively Identified MACE Within 30 Days Than Screening Based on hs-cTnT AloneIn a prospective observational study enrolling 1,038 patients presenting to the emergency department (ED) with chest pain, an extended algorithm comprising hs-cTnT results at 1 h combined with history and ECG, identified 60% of all patients for rule-out and had a higher sensitivity than the troponin algorithm alone (97.5% vs 87.6%; p< 0.001). The negative predictive value was 99.5% and the likelihood ratio was 0.04 with the extended algorithm vs 97.8% and 0.17, respectively, with the troponin algorithm. The extended algorithm ruled-in 14% of patients with a higher sensitivity (75.2% vs 56.2%; p< 0.001) but a slightly lower specificity (94.0% vs 96.4%; p< 0.001) than the troponin algorithm. The rule-in arms of both algorithms had a likelihood ratio >10 (Mokhtari A et al, J Am Coll Cardiol 2016;67:1531-1540)... (excerpt
The Role of Fluorodeoxyglucose Standardized Uptake Value in Diagnosis, Staging and Restaging of Non-Small Cell Lung Cancer
Full text linkMolecular imaging with [18F]-fluorodeoxyglucose positron emission tomography / computed tomography ([18F]FDG-PET/CT) has become part of the standard of care in oncology patients. In oncology, the quantification for the analysis of PET data is an important tool for tumor diagnosis, staging, determination of prognosis and assessment of response to treatment. In clinical practice, standardized uptake value (SUV), a semi-quantitative parameter, is the most widely used parameter for the analysis of tracer uptake in PET imaging. The purpose of this review is to evaluate the role of the SUV in diagnosis, staging and restaging of the lung cancer, and also to establish the differences in [18F]FDG uptake across different histopathological subtypes of non-small lung cancer (NSCLC). Furthermore another purpose of the study is to gather and compare the SUVmax cut-off values, in differentiating benign from malignant lesions, in assessing the response to treatment and finally to identify the optimal threshold
Idiopathic Intracranial Hypertension: Epidemiology, pathophysiology, clinical features and contemporary management.
Full text linkIdiopathic Intracranial Hypertension (IIH) is a syndrome of increased intracranial pressure (ICP) without evident cause. The exact pathogenesis of IIH remains elusive but it is also plausible that the syndrome represents the common final pathway of several different mechanisms. IIH has an estimated incidence of 1-3 per 100 000 and a predilection for obese women of childbearing age. Presentation involves symptomatology and semiology of elevated intracranial pressure with headache being the most common. Visual disturbances can be devastating, progressive and may result in permanent visual loss. Moreover, pulsatile tinnitus is frequently encountered. However, asymptomatic presentations are also not uncommon with patients diagnosed after routine ophthalmological examination illustrates papilledema. Diagnosis is based upon the Friedman’s criteria. Absence of hydrocephalus or mass lesion and normal cerebrospinal fluid (CSF) composition need to be confirmed. Several treatment modalities have been suggested, varying from non-surgical (weight loss, drugs such as acetazolamide, serial lumbar puncture) to interventional and surgical (CSF diversion procedures, optic nerve sheath fenestration (ONSF), endovascular venous sinus stenting, or even bariatric surgery). There are very few RCTs to critically assess these therapies and, consequently, no consensus on the optimal management of IIH.Â
Late Onset of Severe Symptoms in a Patient with Wolff-Parkinson-White Syndrome with Misleading ECG Pattern of the Accessory Pathway Origin Undergoing Successful Ablation
No full textThe case of a female patient with symptomatic Wolff-Parkinson-White syndrome is presented with very late onset of symptoms at the age of 65 years, who had an apparent left-sided posteroseptal accessory pathway, which was ablated via a right-sided approach. A subepicardial location was strongly suspected within the coronary sinus ostium at the origin of the middle cardiac vein by applying both ECG and fluoroscopic criteria
Clinical Heterogeneity of Common Variable Immunodeficiency
Full text linkCommon variable immunodeficiency (CVID) is the most common, clinically relevant, primary immunodeficiency (PID). In the western world the incidence of this disease is about 1:50000. CVID is characterized by hypogammaglobulinemia which involves in all cases immunoglobulin G (IgG), in about 70-80% of cases immunoglobulin A (IgA) and in about 50% of cases immunoglobulin M (IgM). Additionally, patients with CVID develop weak or no immunization responses against polysaccharide (mainly) and protein antigens. Clinical manifestations of CVID may present either early in childhood or late in adulthood, usually between the third and fourth decade of life. The range of CVID clinical manifestations is broad. Underlying CVID should be considered mainly in cases of patients who present with recurrent or persistent bacterial infections of the upper or lower respiratory tract. The possibility of underlying CVID has also to be examined during laboratory investigation of various clinical syndromes, such as lymphadenopathy, hepatosplenomegaly, chronic diarrhea, or malabsorption, and also of autoimmune cytopenias such as idiopathic thrombocytopenic purpura and autoimmune hemolytic anemia. It is noteworthy, that autoimmune diseases and malignancies in the form of lymphoma and neoplasm of the gastrointestinal tract occur with increased incidence in CVID patients in comparison to the general population. Treatment strategy of CVID patients should not be limited to immunoglobulin substitution therapy (administered either intravenously or subcutaneously), but it also has to target effective management of infections and early diagnosis of occurring malignancies (lymphomas and gastrointestinal tumors) through systematic patient monitoring. With regard to life expectancy of CVID patients, two recently published large retrospective studies showed that CVID patients suffering only from infections had prolonged overall survival compared to those who presented with other CVID clinical manifestations. Exclusion of all potential causes of secondary hypogammaglobulinemia is mandatory for establishing the diagnosis of CVID. Also, in some CVID cases, differential diagnosis from other PID may be required, such as X-linked agammaglobulinemia (XLA), antibody deficiency with increased IgM (Hyper-IgM syndrome), and X-linked lymphoproliferative syndrome (XLP)
Cardiology News / Recent Literature Review / First Quarter 2016
Full text linkACC 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, 27-31/8/2016HCS Panhellenic Congress: Athens, 20-22/10/2016TCT Conference: Washington, DC, 29/10-2/11/2016AHA Scientific Sessions: New Orleans, 12-16/11/2016Exercise-Based Cardiac Rehabilitation Reduces the Risk of Cardiovascular (CV) Mortality and Hospital Admission and Improves Quality of Life in Patients With Coronary Heart Disease Meta-analyses of exercise-based cardiac rehabilitation (CR) studies (n=63) comprising 14,486 participants with median follow-up of 12 months indicated that CR led to a reduction in CV mortality (relative risk: 0.74) and the risk of hospital admissions (relative risk: 0.82). There was no significant effect on total mortality, myocardial infarction, or revascularization. The majority of studies (14 of 20) showed higher levels of health-related quality of life in 1 or more domains following exercise-based CR compared with control subjects (Anderson L et al, J Am Coll Cardiol 2016;67:1-12).Coronary CT Angiography (CCTA), Applied Early in Suspected Acute Coronary Syndrome (ACS), is Safe and Associated with Less Outpatient Testing and Lower Costs. However, in the Era of hs-Troponins, it does not Identify more Patients with Significant CAD Requiring Coronary Revascularization, nor does it Shorten Hospital Stay or Allow for More Immediate Discharge from The Emergency Department (ED)Among 500 patients (aged 54 ± 10 years, 47% women) with symptoms suggestive of an ACS at the ED, there was no difference in the primary endpoint (22 - 9% patients underwent coronary revascularization within 30 days in the CCTA group and 17 - 7% in the standard care group; p= NS). Discharge from the ED was not more frequent after CCTA (65% vs 59%, p= NS), and length of stay was similar (6.3 h in both groups; p= NS). The CCTA group had lower direct medical costs (€337 vs. €511, p< 0.01) and less outpatient testing after the index ED visit (10 - 4% vs 26 - 10%, p< 0.01). There was no difference in incidence of undetected ACS (Dedic A et al, J Am Coll Cardiol 2016; 67:16-26).Cost-Effectiveness of Transcatheter Aortic Valve Implantation (TAVI) with a Self-Expanding Prosthesis vs Surgical Aortic Valve Replacement (AVR): TAVI in Patients at High Risk for Complications with AVR Provides Important Incremental Health Benefits at Reasonable Incremental Costs and is an Acceptable Value for the U.S. Health Care SystemRelative to AVR, TAVI reduced initial length of stay an average of 4.4 days, decreased the need for rehabilitation services at discharge, and resulted in superior 1-month quality of life. Index admission and projected lifetime costs were higher with TAVI than with AVR (differences 17,849 per patient, respectively), whereas TAVI was projected to provide a lifetime gain of 0.32 quality-adjusted life-years (QALY; 0.41 LY) with 3% discounting. Lifetime incremental cost-effectiveness ratios were 43,114 per LY gained. N.B.: mean procedure costs: 37,920 for TAVI & 14,258 for AVR (Reynolds MR et al, J Am Coll Cardiol 2016;67:29-38)... (excerpt
Milk Thistle: Its Anti-Tumor Potential
Full text linkMilk thistle has been used for treating liver disorders since approximately 2000 years. Silybum marianum and its seeds contain a whole family of natural compounds, called flavonolignans. Silimarin is a dry mixture of these compounds, which are extracted after processing with ethanol, methanol, and acetone. Silimarin contains mainly silibin A, silibin B, taxifolin, isosilibin A, isosilibin B, silichristin A and silidianin. Milk thistle has been suggested to inhibit cell proliferation and to induce apoptosis, while having anti-angiogenic properties, too. Its mechanisms of action involve inhibition of tumor angiogenesis biomarkers (CD31 and nestin) and molecules regulating angiogenesis (VEGF, VEGFR1, VEGFR2, phospho-Akt and HIF-1a), while other pathways such as the Wnt/β-catenin pathway, cyclin-dependent kinases and MAPK have also been implicated in its actions. Ongoing research has focused on the improvement of milk thistle’s bioavailability and its use as an adjuvant in standardized chemotherapy in the near future