Administration Of Beta-blockers Research Articles

Outcomes of subcutaneous implantable cardioverter defibrillators: UK tertiary centre experience

Abstract Introduction Subcutaneous implantable cardioverter–defibrillators (S-ICDs) were introduced to address limitations associated with the transvenous ICDs (TVICDs). The programming features of the S-ICDs is however restricted compared to TVICDs. Our investigation aims to assess the outcomes of S-ICDs that have been implanted at our institution. Purpose To assess the outcomes of S-ICDs implanted at a tertiary healthcare centre in the United Kingdom. Methods A retrospective analysis was conducted, encompassing data from all individuals who underwent S-ICD implantation at our institution between January 2011 to April 2023 (n=240). Complications were categorized as device-related complications or inappropriate shock (IAS). All occurrences of IAS; lead revisions; infection; pocket hematoma requiring drainage, blood transfusion, or prolongation of hospitalization; and other complications prompting medical or surgical intervention were documented. The underlying causes and outcomes of IAS were reviewed. If S-ICD was either deactivated or explanted, the reasons for such actions were documented. Results Among the 240 patients included in the study, the average age is 46 years, with 66% being male. The average body mass index (BMI) is 27.8 and the ejection fraction (EF) is 43.3%. Comprehensive baseline characteristics are outlined in Table 1. Defibrillation testing (DFT) is a standard practice in our institution to ensure the integrity of S-ICDs and was conducted in all patients unless contraindicated. The success rate of DFT among attempted patients was 73%. The cumulative incidence of device-related complications over the study period was 15%. Eleven patients (4.6%) experienced IAS with T-wave oversensing as the leading cause. Patients undergoing S-ICD implantation for secondary prevention were found to be more susceptible to experiencing IAS (8 Vs 3, p=0.005) but no other baseline characteristics exhibited an association with any complications. The administration of beta-blockers and device reprogramming prevented further IAS in five patients. The remaining patients necessitated interventions such as lead revision, ablation therapy, switching to TVICD, or upgrading to cardiac resynchronisation therapy (CRT). A total of 38 patients required device explant or deactivation. The primary cause for such actions was due to patient mortality. The other notable causes included S-ICD infection, premature battery depletion, and IAS (Table 2). Conclusion Based on our findings, S-ICD emerges as a useful option for the prevention of sudden cardiac death in many patients. The decision regarding the selection of the appropriate ICD for individual patients warrants comprehensive discussion, encompassing a thorough discussion of advantages and disadvantages with the patients. We anticipate that the data elucidated in this study will be valuable in informing future patient care considerations.Table 1Baseline CharacteristicsTable 2Reasons

Impact of early administration of beta-blocker and RAS inhibitor during VA-ECMO treatment for cardiogenic shock; the post-hoc study of the EARLY-UNLOAD trial

Abstract Funding Acknowledgements None. Background/introduction No data about timing and impact of beta-blocker (BB) or renin-angiotensin-aldosterone system inhibitor (RASi) administration for cardiogenic shock (CS) treated with venoatrial extracorporeal membrane oxygenation (VA-ECMO). Purpose To analyze an impact of early administration of BB or RASi during VA-ECMO treatment. Methods This study is a post-hoc analysis of the EARLY-UNLOAD trial (NCT04775472), the trial evaluated an impact of an early prophylactic unloading strategy using left atrial cannulation (LAC) performed within 12 hours from the initiation of VA-ECMO treatment for CS. Among total population (N=116), patients whose lactate was normalized during VA-ECMO and survived more than 2 days were included in this analysis (N=103). Patients were classified whether each medication (BB, RASi or one of BB or RASi) was administered during VA-ECMO or not. The primary endpoint was all-cause mortality. Survival analysis for a primary outcome and landmark analysis for all-cause mortality during different periods (<10 days, 10 to 30 days) were performed. Results BB, RASi, and BB or RASi were administered in 71.8%, 72.8%, and 83.5% of patients, respectively, during VA-ECMO treatment. In early treatment groups, Both BB and RASi were initiated on day 1 (as median). Duration of VA-ECMO treatment was longer in a group who treated with BB during VA-ECMO (8.5 days, vs 5.0 days as median, P = 0.003), and for RASi, it was comparable (8.0 days vs 7.0 days, P = 0.609). Incidence of 30-day all-cause mortality at were statistically comparable between groups (figure 1). The results of survival analysis are described in the figure 2. In Kaplan-Meier analysis, BB, RASi, and BB or RASi during VA-ECMO treatment was not associated with lower probability of 30-day all-cause mortality. Landmark analysis, however, showed lower probability of 10-day mortality in the group treated with BB (P by log-rank test = 0.045), RASi (P = 0.008) and BB or RASi (P=0.005) during VA-ECMO. Multivariate Cox proportional modellings also provided lower risk of 10-day all-cause mortality in groups with BB treatment (Hazard ratio [HR] = 0.26, 95% confidence interval [CI]=0.10-0.69, P = 0.007), RASi treatment (HR = 0.22, 95% CI = 0.08-0.56, P = 0.001) or BB or RASi (HR = 0.15, 95% CI = 0.05-0.41, P < 0.001) during VA-ECMO. RASi (HR = 0.47, 95% CI = 0.22-0.97, P = 0.041) or BB or RASi (HR = 0.37, 95% CI = 0.15-0.93, P = 0.038) treatment during VA-ECMO was also associated with lower risk of 30-day all-cause mortality. Conclusions In this post-hoc analysis of the EARLY-UNLOAD trial, administration of BB or RASi during VA-ECMO treatment for CS was associated with lower risk of short-term mortality.

Enhanced Recovery After Surgery Cardiac Society turnkey order set for prevention and management of postoperative atrial fibrillation after cardiac surgery: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023

BackgroundPostoperative atrial fibrillation (POAF) is a prevalent complication following cardiac surgery that is associated with increased adverse events. Several guidelines and expert consensus documents have been published addressing the prevention and management of POAF. We aimed to develop an order set to facilitate widespread implementation and adoption of evidence-based practices for POAF following cardiac surgery. MethodsSubject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for POAF. Orders derived from consistent class I or IIA or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence appear in italic type. ResultsPreoperatively, the recommendation is to screen patients for paroxysmal or chronic atrial fibrillation and initiate appropriate treatment based on individual risk stratification for the development of POAF. This may include the administration of beta-blockers or amiodarone, tailored to the patient's specific risk profile. Intraoperatively, surgical interventions such as posterior pericardiotomy should be considered in selected patients. Postoperatively, it is crucial to focus on electrolyte normalization, implementation strategies for rate or rhythm control, and anticoagulation management. These comprehensive measures aim to optimize patient outcomes and reduce the occurrence of POAF following cardiac surgery. ConclusionsDespite the well-established benefits of implementing a multidisciplinary care pathway for POAF in cardiac surgery, its adoption and implementation remain inconsistent. We have developed a readily applicable order set that incorporates recommendations from existing guidelines.

Administration and effects of beta blockers and oxandrolone in severely burned adults: a post hoc analysis of the RE-ENERGIZE trial.

Prospective randomized trials in severely burned children have shown the positive effects of oxandrolone (OX), beta blockers (BB) and a combination of the two (BBOX) on hypermetabolism, catabolism and hyperinflammation short- and long-term post-burn. Although data on severely burned adults are lacking in comparison, BB, OX and BBOX appear to be commonly employed in this patient population. In this study, we perform a secondary analysis of an international prospective randomized trial dataset to provide descriptive evidence regarding the current utilization patterns and potential treatment effects of OX, BB and BBOX. The RE-ENERGIZE (RandomizEd Trial of ENtERal Glutamine to minimIZE Thermal Injury, NCT00985205) trial included 1200 adult patients with severe burns. We stratified patients according to their receipt of OX, BB, BBOX or none of these drugs (None) during acute hospitalization. Descriptive statistics describe the details of drug therapy and unadjusted analyses identify predisposing factors for drug use per group. Association between OX, BB and BBOX and clinical outcomes such as time to discharge alive and 6-month mortality were modeled using adjusted multivariable Cox regressions. More than half of all patients in the trial received either OX (n = 138), BB (n = 293) or BBOX (n = 282), as opposed to None (n = 487, 40.6%). Per study site and geographical region, use of OX, BB and BBOX was highly variable. Predisposing factors for the use of OX, BB and BBOX included larger total body surface area (TBSA) burned, higher acute physiology and chronic health evaluation (APACHE) II scores on admission and younger patient age. After adjustment for multiple covariates, the use of OX was associated with a longer time to discharge alive [hazard ratio (HR) 0.62, confidence interval (CI) (0.47-0.82) per 100% increase, p = 0.001]. A higher proportion of days on BB was associated with lower in-hospital-mortality (HR: 0.5, CI 0.28-0.87, p = 0.015) and 6-month mortality (HR: 0.44, CI 0.24-0.82, p = 0.01). The use of OX, BB and BBOX is common within the adult burn patient population, with its use varying considerably across sites worldwide. Our findings found mixed associations between outcomes and the use of BB and OX in adult burn patients, with lower acute and 6-month-mortality with BB and longer times to discharge with OX. Further research into these pharmacological modulators of the pathophysiological response to severe burn injury is indicated.

Prevention of activated brown adipose tissue on 18F-FDG-PET scans of young lymphoma patients: results of an ancillary study within the EuroNet-PHL-C2 trial

Activated brown fat (aBAT) is known to affect the evaluation of 18F-FDG PET scans, especially in young patients. The aim of this study was to determine factors influencing the occurrence of aBAT, and to investigate the effectiveness of the two preventive measures, warming and beta-blocker (propranolol) administration. Five-hundred-twenty-eight 18F-FDG-PET scans of 241 EuroNet-PHL-C2 trial patients from 41 nuclear medicine departments in Germany and Czech Republic were screened for aBAT. The occurrence of aBAT was analyzed with patient characteristics (age, sex, body mass index, predisposition to aBAT), weather data at the day of 18F-FDG PET scanning as well as the preventive measures taken. Potentially important factors from univariate analyses were included into a logistic regression model. Warming as a preventive measure was used in 243 18F-FDG-PET scans, propranolol was administered in 36, warming and propranolol were combined in 84, and no preventive measures were taken in 165 scans. Whereas age, sex and body mass index had no clear impact, there was an individual predisposition to aBAT. Logistic regression model revealed that the frequency of aBAT mainly depends on the outside temperature (p = 0.005) and can be effectively reduced by warming (p = 0.004), the administration of unselective beta-blocker or the combination of both. Warming is a simple, cheap and non-invasive method to reduce the frequency of aBAT. However, the effect of warming decreases with increasing outside temperatures. Administration of propranolol seems to be equally effective and provides advantages whenever the positive effect of warming is compromised. The combination of both preventive measures could have an additive effect.

Ten year evolution of clinical characteristics and short-term outcome of patients admitted with heart failure

Abstract Background/Introduction Heart failure (HF) continues to be a leading cause of morbidity, decreased quality of life (QoL) and mortality worldwide. Contributing to decreased QoL is the high rehospitalization rate, which is often related to non-cardiac causes, highlighting the important multimorbidity of the HF population. Detailed clinical and outcome data for HF admissions in Belgium over time are only scarcely available. Purpose We aimed to evaluate and compare two groups of patients admitted with HF ten years apart, regarding clinical characteristics, comorbidities, use of HF medication and devices, as well as rehospitalization rate and all-cause mortality three months post-discharge. Methods This is a monocentric retrospective observational cohort study conducted in Belgium. Two groups of patients admitted for acute decompensated HF who were discharged alive were included and compared: 340 patients during 2011-2012 and 319 patients during 2021-2022. Results The two cohorts did not differ significantly regarding age (77.3 vs. 78.4 years), gender (47.4 vs. 44.5% women), number of patients with HF with reduced ejection fraction (47.4 vs. 48.6%) and NT-proBNP on admission (8514 vs. 7398 pg/mL). Similarly, comorbidities including diabetes, chronic obstructive pulmonary disease, peripheral artery disease, stroke and renal failure were comparable in both groups. Concerning medical therapy at discharge, mineralocorticoid receptor antagonists (MRA) were used significantly more frequently in the latest cohort. However, there was no change in administration of beta-blockers or renin angiotensin aldosterone system antagonists. As part of the implementation of new therapies for heart failure with reduced ejection fraction, 29% of patients were prescribed sodium-glucose cotransporter-2 (SGLT-2) inhibitors, while sacubitril/valsartan was given in 13% of the cases. The use of internal defibrillators (ICD) and resynchronization devices (CRT) doubled from 2011-2012 to 2021-2022 (3.9 vs. 9.6%, p = 0.002). In-hospital length of stay decreased significantly over a ten-year period across all ejection fraction subgroups from 7 to 5 days (figure 1). The combined outcome of rehospitalization for HF and all-cause mortality three months post-discharge remained constant at approximately 20% (figure 2). Conclusion Clinical characteristics and comorbidities of patients admitted with acute decompensated HF did not change significantly between 2011 and 2022. Uptake of evidence-based medicine for HF increased, especially for MRA, SGLT-2 inhibitors and sacubitril/valsartan, as did the use of ICD and CRT, but still with considerable potential for improvement. Although in-hospital length of stay decreased significantly over time, rehospitalization rates for HF and all-cause mortality within 90 days post-discharge remained high and did not improve. These sobering results illustrate the need for continuing efforts to improve the care and outcome of HF patients.

Abstract 13323: Impact of an Institutional Process Change Adopting End-Systolic Coronary CTA Acquisition on Patient Throughput and Image Quality

Introduction: Prospective ECG-triggered end-systolic coronary computed tomographic angiography (CCTA) acquisition is less prone to motion artifacts with arrhythmias and high heart rates, and with increasing utilization, has the potential to improve scan and CT laboratory efficiency by reducing the need for IV/oral beta-blockers (BB) prior to the scan. Methods: We implemented an institutional process change in CCTA performance effective January 2023, transitioning from prospective ECG-triggered mid-diastolic acquisitions supervised by a physician at the scanner to an algorithmic approach with prospective end-systolic acquisition (200-400 ms after R peak) without BB administration, all on 3 rd -generation 192 slice dual-source scanners. We reviewed 100 consecutive CCTAs done pre- and post-process change in Jan 2022 and Jan 2023. Two experienced CCTA readers assessed segmental image quality by consensus using an 18-segment SCCT model on a 5-point Likert scale (1=non-interpretable; 2=poor; 3=satisfactory; 4=good; 5=excellent). Results: Post-process change, median overall patient appointment [94 (78 - 127) min vs. 69 (53 - 86) min; P < 0.001] and scan times [12 (10 - 16) min vs. 7 (6 - 9) min; P <.001] were significantly lower, and patient throughput doubled [2 (2 - 3)/day vs. 4 (3 - 6)/day; P =.024]. Median segmental image quality score decreased from excellent to good [5 (4 - 5) vs. 4 (4 - 5); P <.001], with a decrease in signal-noise ratio [23.5 (18 - 28.8) vs. 11.8 (8.7 - 14.7); P <.001], and no significant difference in poor or non-interpretable segments in the end-systolic cohort. More scans were repeated with end-systolic scans (10% vs. 18%), with no significant change in radiation dose (Table 1). Conclusion: Utilizing prospective ECG-triggered end-systolic acquisition avoided the use of BB, significantly reduced scan times, doubled patient throughput, at similar radiation doses, and maintained diagnostic performance with only a mild compromise in image quality.

Çocukluk Çağı Benign Baş Boyun Kitlelerinde Tanı ve Tedavi Yaklaşımı

Objective: Head and neck masses are frequently encountered in childhood. Radiological characterization of these lesions plays a crucial role in determining the appropriate treatment approach. At this stage, considering radiation exposure, radiological treatment and, if necessary, surgery should be directed. This study, it was aimed to discuss the diagnostic approach in childhood benign head and neck masses.
 Methods: A retrospective analysis was conducted on 64 pediatric patients who presented with head and neck masses and underwent radiological imaging between 2018 and 2022. Demographic data, radiological diagnostic methods, lesion localization, characterization, treatment approaches, and pathological findings of patients with congenital and acquired masses were obtained from the hospital system.
 Results: The distribution of age and gender among the 64 patients was similar across groups. Head and neck masses were predominantly located in the anterolateral cervical triangle. Thyroglossal duct cysts were the most common cystic masses, displaying mixed sonographic characteristics. Venolymphatic malformations (VLM) were the second most frequently observed masses, predominantly exhibiting cystic features. Hemangiomas were the most common solid masses encountered. In addition, while the cystic lesions were most frequently congenital, the solid ones were acquired.
 Regarding treatment planning, 32 patients (50%) underwent surgical intervention. Among the patients, 15.6% of the patients underwent sclerotherapy at least once. Medical treatment involved non-selective beta-blocker administration in 10 (15.6%) patients.
 Conclusion: The etiology of childhood head and neck masses encompasses a wide spectrum. Therefore, accurate diagnosis plays a crucial role in guiding clinicians toward appropriate medical and/or surgical treatment options.

Association of Early Beta-Blocker Exposure and Functional Outcomes in Critically Ill Patients With Moderate to Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study.

We aimed to 1) describe patterns of beta-blocker utilization among critically ill patients following moderate-severe traumatic brain injury (TBI) and 2) examine the association of early beta-blocker exposure with functional and clinical outcomes following injury. Retrospective cohort study. ICUs at 18 level I, U.S. trauma centers in the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. Greater than or equal to 17 years enrolled in the TRACK-TBI study with moderate-severe TBI (Glasgow Coma Scale of <13) were admitted to the ICU after a blunt TBI. None. Primary exposure was a beta blocker during the first 7 days in the ICU, with a primary outcome of 6-month Glasgow Outcome Scale-Extended (GOSE). Secondary outcomes included: length of hospital stay, in-hospital mortality, 6-month and 12-month mortality, 12-month GOSE score, and 6-month and 12-month measures of disability, well-being, quality of life, and life satisfaction. Of the 450 eligible participants, 57 (13%) received early beta blockers (BB+ group). The BB+ group was on average older, more likely to be on a preinjury beta blocker, and more likely to have a history of hypertension. In the BB+ group, 34 participants (60%) received metoprolol only, 19 participants (33%) received propranolol only, 3 participants (5%) received both, and 1 participant (2%) received atenolol only. In multivariable regression, there was no difference in the odds of a higher GOSE score at 6 months between the BB+ group and BB- group (odds ratio = 0.86; 95% CI, 0.48-1.53). There was no association between BB exposure and secondary outcomes. About one-sixth of subjects in our study received early beta blockers, and within this group, dose, and timing of beta-blocker administration varied substantially. No significant differences in GOSE score at 6 months were demonstrated, although our ability to draw conclusions is limited by overall low total doses administered compared with prior studies.

Drugless and radiographer led: the start of a new era for CT coronary angiography

ObjectiveSince inception CT coronary angiography (CTCA) has required facilitating beta blockers (BB). However, CT technology has improved rapidly as has radiographer and reporter expertise. Using these factors, we instituted a...

Coronary CTA for Acute Chest Pain in the Emergency Department: Comparison of 64-Detector Row Single-Source and Third-Generation Dual-Source Scanners.

Background: When performing coronary CTA in the emergency department (ED), a contemporary scanner with improved temporal resolution may eliminate the need to administer beta blockers for heart rate (HR) control, thereby expediting workup. Objective: To compare ED length-of-stay (LOS), image quality, frequency of nondiagnostic examinations, and other clinical outcomes between patients undergoing coronary CTA in the ED by a single-source CT (SSCT) scanner with HR control versus a dual-source CT (DSCT) scanner without HR control. Methods: This retrospective study included 509 patients (mean age, 52.1±15.1 years; 283 men, 226 women) at low-to-intermediate risk for acute coronary syndrome who underwent coronary CTA for acute chest pain during off hours in a single ED from March 1, 2020 to April 25, 2022. A total of 205 patients initially underwent CTA using a 64-detector SSCT with HR control (oral beta-blocker administration if HR was >65 beats per minute); following scanner replacement on April 26, 2021, 304 patients underwent CTA using a third-generation DSCT without HR control. Groups were compared in terms of ED LOS and CT completion time (time from ordering of CTA to completion of acquisition) using propensity score matching, and additional endpoints including image quality and nondiagnostic examinations based on radiology reports. Results: DSCT group, compared with SSCT group, showed no significant difference in median ED LOS (505 vs 457 minutes; P=.37), but shorter median CT completion time (95 vs 117 minutes; P<.001); based on mediation analysis, 89% of reduction in CT completion time for DSCT was attributed to absence of HR control. DSCT group, compared with SSCT group, showed higher frequency of examinations with good or excellent image quality (87.8% vs 60.0%, P<.001) and lower frequency of nondiagnostic examinations (1.6% vs 6.3%, P=.01), but no significant difference in frequencies of emergent cardiology consultation, invasive angiography, ED disposition, or coronary revascularization (all P>.05). No patient in either group experienced 30-day all-cause mortality or major adverse cardiovascular event. Conclusion: Use of a DSCT scanner for coronary CTA can eliminate need for beta-blocker administration for HR control while decreasing nondiagnostic examinations. Clinical Impact: A DSCT scanner can expedite clinical processes in the ED.

Clinical Efficacy and Safety of Early Intravenous Administration of Beta-Blockers in Patients Suffering from Acute ST-Segment Elevation Myocardial Infarction Without Heart Failure Undergoing Primary Percutaneous Coronary Intervention: A Study-Level Meta-Analysis of Randomized Clinical Trials.

Several clinical studies have produced diverse results regarding the efficacy and safety of early intravenous beta-blockers in patients with acute ST-segment elevation myocardial infarction (STEMI). A study-level meta-analysis of randomized clinical trials (RCTs) comparing early intravenous beta-blockers versus placebo or routine care in STEMI patients undergoing primary percutaneous coronary intervention (PCI) was performed. A database search was conducted using PubMed, EMBASE, the Cochrane Library, and Clinicaltrials.gov for randomized clinical trials (RCTs) that compared intravenous beta-blockers versus placebo or routine care in STEMI patients who underwent primary PCI. The efficacy outcomes were infarct size (IS, % of LV) and the myocardial salvage index (MSI) based on magnetic resonance imaging, electrocardiographic findings, heart rate, ST-segment reduction percent (STR%), and complete STR. Safety outcomes included arrhythmias in the first 24 h (ventricular tachycardia and fibrillation [VT/VF], atrial fibrillation [AF], bradycardia, and advanced atrioventricular [AV] block), cardiogenic shock and hypotension during hospitalization, left ventricular ejection fraction (LVEF), and major adverse cardiovascular events (cardiac death, stroke, reinfarction, and heart failure readmission) at follow-up. Seven RCTs with 1428 patients were included in this study, with 709 patients in the intravenous beta-blockers and 719 in the control group. Intravenous beta-blockers improved MSI compared to the control group (weighted mean difference [WMD] 8.46, 95% confidence interval [CI] 3.12-13.80, P = 0.002, I2 = 0%), but no differences were observed in IS (% of LV) between groups. Compared to the control group, the intravenous beta-blockers group had a lower risk of VT/VF (relative risk [RR] 0.65, 95% CI 0.45-0.94, P = 0.02, I2 = 35%) without an increase of AF, bradycardia, and AV-block and significantly decreased HR, hypotension. LVEF at 1 week ± 7 days (WMD 2.06, 95% CI 0.25-3.88, P = 0.03, I2 = 12%) and 6 months ± 7 days (WMD 3.24, 95% CI 1.54-4.95, P = 0.0002, I2 = 0%) was improved in the intravenous beta-blockers group compared to the control group. Subgroup analysis showed that intravenous beta-blockers before PCI decreased the risk of VT/VF and improved LVEF compared to the control group. Furthermore, sensitivity analysis showed that patients with a left anterior descending (LAD) artery lesion had a smaller IS (% of LV) in the intravenous beta-blockers group compared to the control group. Intravenous beta-blockers improved the MSI, decreased the risk of VT/VF in the first 24 h, and were associated with increased LVEF at 1 week and 6 months following PCI. In particular, intravenous beta-blockers started before PCI is beneficial for patients with LAD lesions.

A Retrospective Review of Cardiogenic Shock Development in Patients With ST-Elevation Myocardial Infarction and Percutaneous Coronary Intervention Receiving Early Beta-Blockers.

Beta-blockers (BBs) have proven to improve morbidity and mortality in patients after an ST elevation myocardial infarction (STEMI). Guidelines suggest initiating a BB within 24 hours, except in those with risk factors for developing cardiogenic shock, although published literature is conflicting regarding the true association of these risk factors with shock. This retrospective cohort study aimed to assess whether the presence of defined risk factors was associated with cardiogenic shock after early BB administration in patients with a STEMI and percutaneous coronary intervention. The primary outcome determined the rate of cardiogenic shock development and secondarily determined any characteristics associated with cardiogenic shock in patients who received beta blockers. The population included 299 patients and cardiogenic shock occurred in 8 patients (2.7%). There were no median (interquartile range) differences in age [63 years (60-71) versus 62 years (52-71); P = 0.4965], systolic blood pressure [110 mm Hg (105-115) versus 109 mm Hg (103-114); P = 0.6027], or heart rate [90 (78-104) versus 76 (64-90); P = 0.0697] before BB administration in patients who developed shock versus those who did not, respectively. Hours to BB administration from arrival [15.6 (6.0-54.8) versus 21.9 (10.6-42; P = 0.6968] and the number (%) with anterior infarction [3 (37.5%) versus 107 (36.8%); P = 1.000] were similar between groups. There was a statistically significant higher median (interquartile range) peak troponin [140 ng/mL (54-304) versus 49 ng/mL (16-132); P = 0.0354] in patients who developed shock. Early initiation of a BB in patients with STEMI and percutaneous coronary intervention with risk factors for cardiogenic shock does not seem to be associated with shock in most patients.

Myocardial bridging manifested as acute coronary syndrome: an unusual presentation of the so-called benign coronary anatomy variant

Myocardial bridging is an anatomical variant characterized by a coronary artery that tunneled through the myocardium. Often asymptomatic, myocardial bridging could also go to a further extent, presenting as myocardial ischemia in the form of stable angina pectoris, acute coronary syndrome, arrhythmias, or even sudden cardiac death. Although these are uncommon manifestations, it is still a challenge for physicians when encountering such cases. Additional imaging techniques are often required to diagnose myocardial bridging. This report is about a unique case of a 72-year-old man presenting with acute coronary syndrome (ACS) in the form of unstable angina pectoris (UAP), which was later found to be caused by myocardial bridging on coronary angiography. Following administration of beta-blocker, antiplatelet, and statin, the angina symptoms, as well as ischemic sign on electrocardiography (ECG), were completely resolved.

Coronary CTA Amidst the COVID-19 Pandemic: A Quicker Examination Protocol with Preserved Image Quality Using a Dedicated Cardiac Scanner.

There has been an ongoing debate on the means to minimize the time patients spend at health care providers during the COVID-19 pandemic. We propose a strategy relying solely on intravenous (i.v.) beta-blocker administration for heart-rate (HR) control prior to coronary CT angiography (CCTA). We aimed to assess a potential difference in CCTA image quality (IQ) after implementation of a modified strategy compared to our standard protocol of oral premedication during the first wave of COVID-19. We analyzed CCTA examinations conducted one year before (n = 1511) and after (n = 1064) implementation of this new regime. Examinations were performed both on our 256-slice multidetector CT (MDCT) and dedicated cardiac CT (DCCT) scanners. We used a four-point Likert scale (excellent/good/moderate/non-diagnostic) for IQ assessment of the coronaries. We detected a significant increase in mean HR during examinations on both CT scanners (MDCT: 62.4 ± 10.0 vs. 65.3 ± 9.7, p < 0.001; DCCT: 61.7 ± 15.2 vs. 65.0 ± 10.7, p < 0.001). The rate of moderate/non-diagnostic IQ significantly increased on the MDCT (192/1005, 19.1% vs. 144/466, 30.9%, p < 0.001), while this ratio did not change significantly on the DCCT (62/506, 12.3% vs. 84/598, 14.0%, p = 0.38). The improved temporal resolution of DCCT allows the stand-alone use of i.v. premedication with preserved IQ; hence, the duration of visits can be shortened.

Beta-Blockers for Primary Prevention of Anthracycline-Induced Cardiac Toxicity: An Updated Meta-Analysis of Randomized Clinical Trials.

Cardiotoxicity is a well-recognized complication of chemotherapy with Anthracyclines. However, results from trials evaluating beta-blockers for prevention are controversial. Therefore, we performed a meta-analysis to find whether prophylactic administration of beta-blockers can help prevent Anthracyclines-induced cardiotoxicity. We assessed randomized trials and observational studies where a prophylactic intervention was compared with a control arm in patients with a normal left ventricular ejection fraction (LVEF) receiving Anthracyclines. The primary outcome was EF reduction. The secondary outcome was the development of Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD), defined as a decrease in the LVEF of >10% to a value of <53%. We included 17 trials comprising 1291 patients (671 patients in the intervention arm and 620 in the control arm). Carvedilol was administered in eight studies, and others used bisoprolol, metoprolol, or nebivolol. Compared with baseline, LVEF reduced in both intervention and control groups after chemotherapy (MD = -1.93%, 95% CI: -2.94, -0.92, p = 0.001, I2 = 72.1% vs. MD = -4.78%, 95% CI: -6.51, -3.04, p = 0.001, I 2 = 91.6%, respectively). LVEF was less reduced among the beta-blocker receivers (MD = 3.44%, 95% CI: 1.41-5.46, p = 0.001, I2 = 94.0%). Among the eight studies reporting the incidence of CTRCD, 45 out of 370 participants in the intervention arm and 54 out of 341 in the control arm were reported to experience this complication (RR = 0.76; 95% CI: 0.53,1.09; I 2 = 24.4%; p = 0.235). Treatment with beta-blockers prevents dilatation of the left ventricle, development of diastolic dysfunction, and reduction of LVEF. However, these hemodynamic effects do not translate into a significant reduction in CTRCD incidence and prevention of hospitalization for heart failure or cardiac death.

Diagnosis, complication and treatment of acute salbutamol toxicity

Salbutamol is a well-known example of a short-acting beta agonist that is used as therapy for managing asthma, bronchospasm and chronic obstructive pulmonary disease. Short-acting beta agonist without a controller should only be taken into consideration as needed if symptoms are minimal and there is no asthma-related awakening. Salbutamol's maximal efficacy is based on how it is administered and the formulation that is utilized. Inhaled salbutamol is a first-line treatment for the majority of patients because it provides quick bronchodilation and typically relieves bronchospasm within minutes. Salbutamol immediately relieves the symptoms of acute asthma by relaxing the smooth muscle in the airways and boosting airflow. Patient experiences immediate relief from coughing, wheezing, tightness in the chest, and shortness of breath. Salbutamol's fast alleviation of symptoms may encourage abuse and overuse, especially in adolescents. On the basis of clinical and laboratory results, the diagnosis of salbutamol toxicity can be formed. The management is primarily supportive and includes stopping the harmful agent and using beta blockers to relieve symptoms. The purpose of this research is to review the available information about diagnosis, complication and treatment of acute salbutamol toxicity. Salbutamol overdose may cause tremors, hyperglycemia, lactic acidosis, and cardiac arrhythmias. Treatment for patients with severe symptoms include administration of beta-blockers if there are no contraindications also potassium supplementation, activated charcoal and gastric lavage among commonly used therapeutic strategies. Although salbutamol toxicity is uncommon still the physicians shall be knowledgeable about the diagnosis and management of salbutamol toxicity due to its widespread usage.

#1302161: Mechanism Behind GLP1RA-Induced Refractory Tachycardia: A Case and Literature Review

Sinus tachycardia is a known adverse effect of GLP1 receptor agonists (GLP1 RA). We present a case of a patient who developed symptomatic tachycardia resistant to beta-blockers administration, after starting liraglutide for type 2 diabetes mellitus (T2DM).

Recumbent Ergometer vs Treadmill Cardiopulmonary Exercise Test in HFpEF: Implications for Chronotropic Response and Exercise Capacity

Cardiopulmonary exercise testing (CPET) can identify mechanisms of exercise intolerance in heart failure with preserved ejection fraction (HFpEF), but exercise modalities with differing body positions (eg, recumbent ergometer, treadmill) are broadly used. In this study, we aimed to determine whether body position affects CPET parameters in patients with HFpEF. Subjects with stable HFpEF (n = 23) underwent noninvasive treadmill CPET, followed by an invasive recumbent-cycle ergometer CPET within 3 months. A comparison group undergoing similar studies included healthy subjects (n = 5) and subjects with pulmonary arterial hypertension (n = 6). The peak oxygen consumption (VO2peak) and peak heart rate were significantly lower in the recumbent vs the upright position (10.1 vs 13.1 mL/kg/min [Δ-3 mL/kg/min]; P < 0.001; and 95 vs 113 bpm [Δ-18 bpm]; P < 0.001, respectively). No significant differences were found in the minute ventilation to carbon dioxide production ratio, end-tidal pressure of carbon dioxide or respiratory exchange ratio. A similar pattern was observed in the comparison groups. Compared to recumbent ergometer, treadmill CPET revealed higher VO2peak and peak heart rate response. When determining chronotropic incompetence to adjust beta-blocker administration in HFpEF, body position should be taken into account.

Factors influencing the safety of outpatient coronary CT angiography: a clinical registry study

ObjectivesSince the safety of coronary CT angiography (CTA) is of great importance, especially with regard to widening indications and increasing morbidity, the aim of this study was to assess influencing...