Administration Of Nitroglycerin Research Articles

Early intravenous nitroglycerin use in prehospital setting and in the emergency department to treat patients with acute heart failure: Insights from the EAHFE Spanish registry

Background and objectiveAlthough recommended for the treatment of acute heart failure (AHF), the use of intravenous (IV) nitroglycerin (NTG) is supported by scarce and contradicting evidence. In the current analysis, we have assessed the impact of IV NTG administration by EMS or in emergency department (ED) on outcomes of AHF patients. MethodsWe analyze AHF patients included by 45 hospitals that were delivered to ED by EMS. Patients were grouped according to whether treatment with IV NTG was started by EMS before ED admission (preED-NTG), during the ED stay (ED-NTG) or were untreated with IV NTG (no-NTG, control group). In-hospital, 30-day and 365-day all-cause mortality, prolonged hospitalization (>7 days) and 90-day post-discharge combined adverse events (ED revisit, hospitalization or death) were compared in EMS-NTG and ED-NTG respect to control group. ResultsWe included 8424 patients: preED-NTG = 292 (3.5%), ED-NTG = 1159 (13.8%) and no-NTG = 6973 (82.7%). preED-NTG group had the most severely decompensated cases of AHF (p < 0.001) but it had lower in-hospital (OR = 0.724, 95%CI = 0.459–1.114), 30-day (HR = 0.818, 0.576–1.163) and 365-day mortality (HR = 0.692, 0.551-0.869) and 90-day post-discharge events (HR = 0.795, 0.643–0.984) than control group. ED-NTG group had mortalities similar to control group (in-hospital: OR = 1.164, 0.936–1.448; 30-day: HR = 0.980, 0.819–1.174; 365-day: HR = 0.929, 0.830–1.039) but significantly decreased 90-day post-discharge events (HR = 0.870, 0.780–0.970). Prolonged hospitalization rate did not differ among groups. Five different analyses confirmed these findings. ConclusionsEarly prehospital IV NTG administration was associated with lower mortality and post-discharge events, while IV NTG initiated in ED only improved post-discharge event rate. Further studies are needed to assess the role of early prehospital administration of IV NTG to patients with AHF.

Rapid Intravenous Glyceryl Trinitrate in Ischemic Damage (RIGID) After Stroke: Rationale, Design and Protocol for a Prospective Randomized Controlled Trial

Background: Despite intravenous thrombolysis and endovascular therapy for acute ischemic stroke (AIS), many survivors still have varying degrees of disability. Glyceryl trinitrate (GTN), a nitric oxide (NO) donor, has been previously reported to induce neuroprotection after AIS. The use of GTN to reduce brain damage after stroke remains yet to be elucidated. This study was designed to explore the safety, feasibility, and preliminary efficacy of intravenous administration of GTN after AIS.Methods: A prospective randomized controlled trial is proposed with AIS patients. Participants will be randomly allocated to GTN group and control group with a 1:1 ratio (n = 40). Both groups will be treated with standard therapies according to the current stroke guidelines. Participants allocated to the GTN group will receive intravenous administration of GTN (5 mg GTN in 50 ml saline at a rate of 0.4 mg/h that is continued for 12.5 h/day for 2 days) within 24 h of symptom onset. Participants allocated to the control group will receive intravenous administration at equal capacity of 0.9% normal saline (NS) (total 50 ml/day at 4 ml/h that is continued for 12.5 h/day for 2 days). The primary outcome is safety [systolic blood pressure (SBP) <110 mmHg, headache], while the secondary outcomes include changes in functional outcome and infarction volume.Discussion: Rapid Intravenous Glyceryl Trinitrate in Ischemic Damage (RIGID) is a prospective randomized controlled trial that aims to ascertain the safety, feasibility, and preliminary efficacy of intravenous GTN as a neuroprotection strategy after AIS. These results will provide parameters for future studies as well as provide insights into treatment effects. Any possible neuroprotective qualities of GTN in AIS will also be elucidated.Trial Registration:www.chictr.org.cn, identifier: ChiCTR2100046271.

Effects of ligustrazine on the expression of neurotransmitters in the trigeminal ganglion of a rat migraine model.

BackgroundMigraine is one of the most common neurological diseases which has been treated by active substances from traditional Chinese medicine (TCM), such as ligustrazine, an extract of the Chinese herb Chuanxiong. However, the pathogenesis of migraine and the curative mechanisms of ligustrazine have remained unclear. The genes P2X3, TRPV1, ERK, and c-fos have been implicated to play a role. In this work, we attempted to elucidate the analgesic mechanism of ligustrazine using a classic migraine-representative rat model.MethodsThe migraine rat model was established by administration of nitroglycerin (NTG). Ligustrazine treatment was administered by intravenous injection. The animal’s behavior was continuously recorded, and then trigeminal ganglions (TGs) were isolated. Total RNA was extracted from cells and total protein was extracted from TG. Quantitative real-time polymerase chain reaction (qRT-PCR) and western blot analyses were used to detect the levels of P2X3, TRPV1, c-Fos, and ERK in TG.ResultsLigustrazine could reduce the neurological activities of NTG-induced migraine rats. The rats TG nerve showed varying degrees of expression of P2X3, TRPV1, c-Fos and ERK expression element. Ligustrazine could inhibit over-expression of P2X3, TRPV1, c-fos, and ERK in the TG nerve of NTG-induced migraine rats.ConclusionsOur results demonstrated that ligustrazine had potent activity against NTG-induced migraine rats through inhibition of the c-fos/ERK signaling pathway. This work may provide a comprehensive basis for a better understanding of the pathogenesis of migraine and the curative mechanisms of ligustrazine.

Activation of microglial GLP-1R in the trigeminal nucleus caudalis suppresses central sensitization of chronic migraine after recurrent nitroglycerin stimulation

BackgroundCentral sensitization is considered a critical pathogenic mechanism of chronic migraine (CM). Activation of microglia in the trigeminal nucleus caudalis (TNC) contributes to this progression. Microglial glucagon-like peptide-1 receptor (GLP-1R) activation can alleviate pain; however, whether it is involved in the mechanism of CM has not been determined. Thus, this study aims to investigate the precise role of GLP-1R in the central sensitization of CM.MethodsRepeated nitroglycerin injection-treated mice were used as a CM animal model in the experiment. To identify the distribution and cell localization of GLP-1R in the TNC, we performed immunofluorescence staining. Changes in the expression of GLP-1R, Iba-1, PI3K and p-Akt in the TNC were examined by western blotting. To confirm the effect of GLP-1R and PI3K/Akt in CM, a GLP-1R selective agonist (liraglutide) and antagonist (exendin(9–39)) and a PI3K selective antagonist (LY294002) were administered. Mechanical hypersensitivity was measured through von Frey filaments. To investigate the role of GLP-1R in central sensitization, calcitonin gene-related peptide (CGRP) and c-fos were determined using western blotting and immunofluorescence. To determine the changes in microglial activation, IL-1β and TNF-α were examined by western blotting, and the number and morphology of microglia were measured by immunofluorescence. We also confirmed the effect of GLP-1R on microglial activation in lipopolysaccharide-treated BV-2 microglia.ResultsThe protein expression of GLP-1R was increased in the TNC after nitroglycerin injection. GLP-1R was colocalized with microglia and astrocytes in the TNC and was fully expressed in BV-2 microglia. The GLP-1R agonist liraglutide alleviated basal allodynia and suppressed the upregulation of CGRP, c-fos and PI3K/p-Akt in the TNC. Similarly, the PI3K inhibitor LY294002 prevented nitroglycerin-induced hyperalgesia. In addition, activating GLP-1R reduced Iba-1, IL-1β and TNF-α release and inhibited TNC microglial number and morphological changes (process retraction) following nitroglycerin administration. In vitro, the protein levels of IL-1β and TNF-α in lipopolysaccharide-stimulated BV-2 microglia were also decreased by liraglutide.ConclusionsThese findings suggest that microglial GLP-1R activation in the TNC may suppress the central sensitization of CM by regulating TNC microglial activation via the PI3K/Akt pathway.

B-AB19-04 DIAGNOSIS OF CORONARY VASOSPASM-INDUCED VENTRICULAR FIBRILLATION DURING PERICARDIAL MAPPING

After excluding cardiac genetic and structural abnormalities, idiopathic VF is estimated to account for ∼5% of cases of sudden cardiac death. In these cases, it may be difficult to identify an etiology for VF. We present a case of idiopathic polymorphic VT/VF (pVT/VF) with the diagnosis made in the EP lab. N/A A 47-year-old man had a witnessed cardiac arrest and was found to be in VF. A work-up including coronary angiography was unrevealing; MRI was largely normal, though suggestive of an inferolateral area of subepicardial scar. A subcutaneous ICD (SICD) was placed. He presented to us with recurrent pVT/VF on sotalol resulting in multiple ICD shocks, some of which failed to immediately defibrillate. At EP study, stimulation did not induce sustained ventricular arrhythmias. Standard pericardial access was obtained to permit epi/endo mapping to identify arrhythmogenic substrate. But immediately upon onset of pericardial mapping, ST segment elevation occurred, and the patient developed non-sustained pVT (Figure). Immediate coronary angiography revealed diffuse coronary spasm, most strikingly in the proximal LAD. With administration of intracoronary nitroglycerin, the LAD spasm and pVT/VF resolved; ST segment abnormalities resolved within minutes. DFT testing revealed a normal functioning SICD. He was discharged on long-acting nifedipine and nitrates for coronary vasospasm. Severe coronary vasospasm may cause idiopathic polymorphic VT/VF. Medical therapy with calcium-channel blockers and oral nitrates are the first-line therapy as ICD therapies alone may be ineffective in the setting of on-going spasm and ischemia.

Hypothalamic functional MRI activity in the initiation phase of spontaneous and glyceryl trinitrate-induced migraine attacks.

The hypothalamus has been suggested to be important in the initiation cascade of migraine attacks based on clinical and biochemical observations. Previous imaging studies could not disentangle the changes due to the attack and those due to the trigger compound. With a novel approach, we assessed hypothalamic neuronal activity in early premonitory phases of glyceryl‐trinitrate (GTN)‐induced and spontaneous migraine attacks. We measured the hypothalamic blood oxygen level‐dependent (BOLD) response to oral glucose ingestion with 3T‐functional magnetic resonance imaging (MRI) in 27 women, 16 with migraine without aura and 11 controls group matched for age and body mass index (BMI), on 1 day without prior GTN administration and on a second day after GTN administration (to coincide with the premonitory phase of an induced attack). Interestingly, subgroups of patients with and without GTN‐triggered attacks could be compared. Additionally, five migraineurs were investigated in a spontaneous premonitory phase. Linear mixed models were used to study between‐ and within‐group effects. Without prior GTN infusion, the BOLD response to glucose was similar in migraine participants and controls (P = .41). After prior GTN infusion, recovery occurred steeper and faster in migraineurs (versus Day 1; P < .0001) and in those who developed an attack versus those who did not (P < .0001). Prior GTN infusion did not alter the glucose‐induced response in controls (versus baseline; P = .71). Just before spontaneous attacks, the BOLD‐response recovery was also faster (P < .0001). In this study, we found new and direct evidence of altered hypothalamic neuronal function in the immediate preclinical phase of both GTN‐provoked and spontaneous migraine attacks.

Assessment of coronary artery bypass grafts by multidetector computed tomography

Background Multidetector computed tomography (MDCT) had made a revolution in coronary artery bypass graft (CABG) evaluation owing to high temporal and spatial resolution, besides it being noninvasive and highly effective in assessment of extracoronary manifestations. Objective To evaluate the feasibility of high-quality MDCT in assessment of patients with CABG in comparison with conventional coronary angiography. Patients and methods A total of 50 patients were enrolled for ECG-gated CT of CABGs between May 2020 and September 2020. Patients were subjected to conventional coronary angiography within 10 days after MDCT examination at Al Hussein University Hospital. Administration of beta-blocker and nitroglycerin was done before CT examination. Breath-hold training was mandatory. Results A total of 46 grafts were arterial and 74 were venous. Overall, 36 (78.2%) of the arterial grafts were patent, six (13%) were significantly narrowed, and four (8.8%) were completely occluded. Regarding venous grafts, 52 (70.2%) of them were patent, 14 (19%) were significantly narrowed, and eight (10.8%) were completely occluded. CT angiography compared with the conventional angiography as a gold standard technique gave us a sensitivity of 100%, a specificity of about 98%, and an accuracy of about 93.6% in the assessment of any type of coronary artery grafts. Conclusion MDCT is considered the imaging modality of choice nowadays to evaluate the patency and stenosis of CABGs than the conventional coronary angiography owing to its multiple drawbacks.

ASSESMENT OF CORONARY ARTERY BYPASS GRAFTS BY MULTIDETECTOR CT

Background: Multidetector computed tomography (MDCT) had made a revolution in coronary artery bypass grafts (CABG) evaluation due to high temporal and spatial resolution beside it is beingnon invasive and highly effective in assessment of extra coronary manifestations. Objective: To evaluate the feasibility of high-quality multi-detector computed tomography ((MDCT) in assessment of CABG patients in comparison with conventional coronary angiography. Patients and methods: Fifty patients were enrolled for ECG gated CT of coronary arteries bypass grafts between MAY 2020 and September 2020. Patients subjected to conventional coronary angiography within 10days after MDCT exam. at Al-Hussein University Hospital. Administration of beta blocker and nitroglycerin was done prior to CT exam. Breath hold training was mandatory. Results: Forty six grafts were arterial and 74 were venous. Thirty six of the arterial grafts (78.2 %) were patent, 6 (13 %) were significantly narrowed and 4 (8.8 %) were completely occluded. Regarding venous grafts, 52 (70.2 %) of them were patent, 14 (19 %) were significantly narrowed, 8 (10.8 %) were completely occluded. CT angiography compared to the conventional angiography as a gold standard technique gave us a sensitivity of 100%, a specificity of about 98% and an accuracy of about 93.6% in the assessment of any type of coronary artery grafts. Conclusion: Multi Detector CT is considered the imaging modality of choice at the current days to evaluate the patency and stenosis of coronary artery bypass grafts than the conventional coronary angiography due to its multiple drawbacks.

Vasodilatation by carbon dioxide and sodium nitroglycerin reduces compliance of the cerebral arteries in humans.

What is the central question of this study? Vascular compliance importantly contributes to the regulation of cerebral perfusion and complex mechanisms are known to influence compliance of a vascular bed: while vasodilatation mediates changes in vascular resistance, does it also affect compliance, particularly in the cerebral vasculature? What is the main finding and its importance? Cerebral vasodilatation, elicited by hypercapnia and sodium nitroglycerin administration, reduced cerebrovascular compliance by approximately 26% from baseline. This study provides new insight into mechanisms mediating cerebrovascular compliance. Changes in vascular resistance and vascular compliance contribute to the regulation of cerebral perfusion. While changes in vascular resistance are known to be mediated by vasodilatation, the mechanisms contributing to changes in vascular compliance are complex. In particular, whether vasodilatation affects compliance of the vasculature within the cranium remains unknown. Therefore, the present study examined the impact of two vasodilatation pathways on cerebrovascular compliance in humans. Fifteen young, healthy adults (26±5years, seven females) completed two protocols: (i) sublingual sodium nitroglycerin (SNG; 0.4mg) and (ii) hypercapnia (5-6% carbon dioxide gas mixture for 4 min). Blood pressure waveforms (finger photoplethysmography) and middle cerebral artery blood velocity waveforms (transcranial Doppler ultrasound) were input into a modified Windkessel model and an index of cerebrovascular compliance (Ci) was calculated. During the SNG protocol, Ci decreased 24±17% from baseline ((5.0±2.3)×10-4 cms-1 mmHg-1 ) to minute 10 ((3.6±1.2)×10-4 cms-1 mmHg-1 ; P=0.009). During the hypercapnia protocol, Ci decreased 28±9% from baseline ((4.4±1.9)×10-4 cms-1 mmHg-1 ) to minute 4 ((3.1±1.4)×10-4 cms-1 mmHg-1 ; P<0.001). Cerebral vasodilatory stimuli induced by nitric oxide and carbon dioxide mechanisms reduced compliance of the cerebral vascular bed by approximately 26% from supine baseline values.

Protein kinase Cδ as a neuronal mechanism for headache in a chronic intermittent nitroglycerin model of migraine in mice.

Migraine is one of the most common neurological disorders characterized by recurrent attacks of typically throbbing and unilateral headaches, affecting up to 20% of the population worldwide. Despite the high prevalence and severity of this primary headache disorder, it remains to be a challenge to fully understand and treat migraine headaches. By characterizing and validating a mouse migraine model, this study aimed to investigate the functional contribution of protein kinase C (PKC) isoforms in migraine. In this study, we identified the presence of migraine-like ongoing pain in mice after chronic intermittent treatment with nitroglycerin (NTG). The peptide antagonist of calcitonin gene-related peptide α-CGRP (8-37), but not topiramate nor sumatriptan, effectively blocked ongoing pain and elicited pain relief-induced conditioned place preference in NTG-treated mice. Prominent activation of PKCδ was observed in chronic NTG-treated mice. Functional inhibition of PKCδ significantly attenuated ongoing spontaneous pain in chronic NTG-treated mice. Furthermore, we recapitulated the NTG-triggered migraine behavior in wild-type mice, but not in PKCδ-null mice. In response to repeated administration of NTG, ongoing spontaneous pain was not developed in mice lacking the specific PKC isoform. This study identified the presence of ongoing pain in mice treated with NTG, a known human migraine trigger that closely resembles the common manifestation of spontaneous migraine attacks in humans. These findings demonstrated a critical regulatory role of PKCδ in migraine pathophysiology, which may offer new pharmacological targets for antimigraine treatment.

Glyceryl trinitrate for the treatment of ischaemic stroke: Determining efficacy in rodent and ovine species for enhanced clinical translation

Hypertension is a leading risk factor for death and dependency after ischaemic stroke. However, administering anti-hypertensive medications post-stroke remains contentious with concerns regarding deleterious effects on cerebral blood flow and infarct expansion. This study sought to determine the effect of glyceryl trinitrate (GTN) treatment in both lissencephalic and gyrencephalic pre-clinical stroke models. Merino sheep underwent middle cerebral artery occlusion (MCAO) followed by GTN or control patch administration (0.2 mg/h). Monitoring of numerous physiologically relevant measures over 24 h showed that GTN administration was associated with decreased intracranial pressure, infarct volume, cerebral oedema and midline shift compared to vehicle treatment (p < 0.05). No significant changes in blood pressure or cerebral perfusion pressure were observed. Using optical imaging spectroscopy and laser speckle imaging, the effect of varying doses of GTN (0.69–50 µg/h) on cerebral blood flow and tissue oxygenation was examined in mice. No consistent effect was found. Additional mice undergoing MCAO followed by GTN administration (doses varying from 0–60 µg/h) also showed no improvement in infarct volume or neurological score within 24 h post-stroke. GTN administration significantly improved numerous stroke-related physiological outcomes in sheep but was ineffective in mice. This suggests that, whilst GTN administration could potentially benefit patients, further research into mechanisms of action are required.

Nitroglycerin (NTG) plus whole intracranial radiotherapy for brain metastases (BM) in non-small cell cancer patient (NSCLC): A randomized open label, phase II clinical trial.

9114 Background: Hypoxia has been associated with chemo-radioresistance secondary to Vascular Endothelial Growth Factor Receptor induced by Hypoxia Induced Factor (HIF). Nitroglycerin (NTG) can reduce HIF-1 in cell lines, and this may have anti-angiogenic, pro-apoptotic, and anti-efflux effects. Particularly, EGFR mutated (EGFRm) tumor cell lines have been shown to overexpress both VEGF and HIF. In this phase II study, we evaluated the effect of transdermal NTG on intracranial objective response rate (iORR), intracranial progression-free survival (ICPFS), and overall survival (OS) of NSCLC patients with BM. Methods: We performed an open-label, phase II clinical trial among ninety-six histologically confirmed NSCLC patients with BM. Patients were randomized 1:1 to receive NTG plus WBRT (30 Gy in 10 fractions) or WBRT alone. iORR and ICPFS were evaluated by MRI by two independent, blinded radiologists. Nitroglycerin was administered using a transdermal 36 mg patch, which released 10 mg in 24 hours with a rest interval of 12 hours from Monday-Friday throughout WBRT administration (10 days). Results: Fifty patients were allocated to the control group, while 46 were allocated to the experimental group (NTG); among these 26 (55.3%) had EGFRm in the control group and 21 (44.7%) had EGFRm in the NTG arm. In terms of the iORR, patients in the NTG group had a significantly higher response when compared to controls (56.6% vs. 43.5%; p = 0.024). Additionally, patients who received NTG in addition to WBRT had an independently prolonged ICPFS compared with those who received WBRT alone (27.7 vs. 9.6; HR: 0.470 [95%CI: 0.24-0.89]; p = 0.021). PFS was also positively impacted (HR: 0.519 [95%CI: 0.27-0.98]; p = 0.043). The benefit in terms of iORR and ICPFS (HR: 0.38 [95%CI: 0.16-0.91]; p = 0.030) was particularly important in the EGFRm patient subgroup. No differences were observed in OS. A significantly higher rate of vomiting presented in the NTG arm of the study ( p= 0.016). Conclusions: The concurrent administration of NTG and chemo-radiotherapy improves iORR and ICPFS among NSCLC patients with BM. The benefit is particularly significant in the EGFRm patient subgroup. Clinical trial information: NCT04338867.

Abstract No. 466 Quantitative assessment of the effect of intra-arterial nitroglycerin on hepatocellular carcinoma perfusion using two-dimensional digital subtraction angiography

To evaluate the effects of intra-arterial nitroglycerin on hepatocellular carcinoma perfusion using 2-D perfusion angiography Two-dimensional (2D) perfusion angiograms obtained during planning arteriography for radioembolization of HCCs from September 2019 to February 2020 were retrospectively reviewed. Inclusion criteria included LIRADS-5 lesions and angiographically identifiable tumor and background parenchyma. Exclusion criteria included treated lesions and motion-degraded studies. Tumor and background liver parenchyma 2D perfusion data before and after the administration of intra-arterial nitroglycerin were processed and the area under the curve (AUC) of the time-density curve was calculated. Relative perfusion of HCC to background liver was compared at the 2 time points using a 2-tailed unpaired t-test. Twenty-four arteriograms were reviewed. Twelve were excluded from the analysis due to prior treatment (n = 5), motion degradation (n = 2), and no identifiable background liver (n = 5). Twelve HCCs in 12 patients were included in the final analysis. Mean patient age was 71.7 ± 9.7 years. Ten patients had cirrhosis. Mean maximum tumor dimension was 4.9 ± 2.0 cm. Seven tumors were in the right lobe and 5 in the left lobe. Contrast injection duration was 5 seconds. Mean intra-arterial nitroglycerin dose was 279 ± 69 micrograms. The arteriograms were then analyzed using 2D perfusion software. The ratio of the AUC of HCC to background liver was 2.18 ± 1.11 before intra-arterial nitroglycerin and 3.14 ±1.70 after nitroglycerin administration (P < 0.05). Intra-arterial nitroglycerin significantly increases perfusion to hepatocellular carcinoma when compared to background liver. Further research is needed to determine if nitroglycerin increases the permeability of HCC tumors and thereby increases intra-tumoral dose delivery.

Anesthesia Management in Patient with Placenta Percreta Performed Intra-aortic Ballooning Caesarean Section

&lt;p&gt;Placenta accreta spectrum is one of maternal mortality’s causes which is related with severe obstetric bleeding that requires hysterectomy. The incidence rate of the spectrum placenta increases with increasing caesarean section. Placenta accreta spectrum is also close-related to placenta previa. The aim of this study is to understand perioperative management in patient with placenta percreta performed with intra-aortic ballooning in caesarean section. We are following a case on a 36 year old female patient, multigravida at term pregnant with placenta percreta and history of caesarean section 5 and 2 years ago. The surgeries performed were caesarean section surgery as well as intra-aortic ballooning. Anesthetic technique used was general anesthesia. Operation duration approximately ± 180 minutes, bleeding 1500 cc. After the operation, the patient was admitted to the ICU. The patient going well and discharged from ICU to ward on the second day. After three days in ward, the patient discharged to home. Hemodynamic changes during balloon intra-aortic procedures are of particular concern to anesthetists. This is because the stopping of blood flow to the aorta in this case can cause an increase in blood vessel pressure, where the administration of nitroglycerin at low doses can reduce venous tone resulting in venous vasodilation which will maintain hemodynamic stability during the process of blocking blood vessels with a balloon. From the case we may conclude that anesthesia in pregnant women with placenta accreta spectrum should be carried out with caution and involve a multidisciplinary specialist given its high risk of bleeding. The intra-aortic balloon insertion technique can be an option used to reduce the risk of bleeding in patients with placenta accreta spectrum.&lt;/p&gt;

Effect of intra-arterial vasodilator administration during radial artery access on systemic blood pressure in patients receiving moderate sedation

The hemodynamic effects of intra-arterial vasodilator administration for the prevention of radial artery spasm during transradial access have not been well characterized. This study evaluates the effect of intra-arterial Verapamil and Nitroglycerine administration on systemic blood pressure and its correlation with timing of moderate sedation administration. Institutional review board approval was granted. Patients who underwent transradial access from 4/2018 to 4/2019 and received both intra-arterial vasodilators and moderate sedation were identified and their electronic medical records reviewed. Patients were divided into three cohorts based on the timing of sedation and intra-arterial vasodilator administration. Decrease in systolic blood pressure (SBP) was expressed as means with standard deviation which were then compared using Student's t-test. A total of 84 patients who met inclusion criteria demonstrated an overall mean decrease in SBP of 16.45 mmHg ± 15.45 mmHg. Patients receiving sedation and intra-arterial vasodilators within their expected peak SBP effect times had similar SBP change following the intra-arterial vasodilators as those in whom the interval was greater than 10 min (4.2 mmHg; 95% CI (-4.11 to 12.52), p = 0.3171). Two patients experienced asymptomatic hypotension. Patients undergoing transradial access for procedures utilizing moderate sedation can safely receive intra-arterial Verapamil and Nitroglycerine for prevention of radial artery spasm.

RADIAL-FINGER PULSE WAVE VELOCITY: RESPONSE OF PERIPHERAL SMALLER ARTERIES TO NITROGLYCERIN

Objective: We previously demonstrated a different regional stiffness response of elastic and muscular arteries after the administration of nitroglycerin, leading to an alteration of aortic-brachial stiffness gradient. Peripheral smaller arteries may also respond differently to nitroglycerin. The objectives of this study were 1- to assess the feasibility of measuring arterial stiffness of the hand, i.e. radial-finger pulse wave velocity (RF-PWV) using piezoelectric sensors, and 2- to measure RF-PWV and its response to nitroglycerin. Design and method: This study was conducted in 29 healthy participants (66% were women, mean age was 40.0 ± 15.1 yrs). Piezoelectric sensors (Complior) were place simultaneously on carotid and radial arteries, and tip of the index and/or third finger, to obtain carotid-radial PWV (CR-PWV) and RF-PWV. These measurements were repeated with a subgroup of 11 subjects after 4 minutes of 0.4mg NTG sublingual spray. Raw data were analyzed using Matlab to ensure good quality of signals and adequacy of the foot-to-foot method. Results: Visually, pressure curves at both fingers were obtained with an excellent quality, similar to radial and carotid pressure curves. Identification of the feet of the finger pulse waveforms was optimal with the second derivative algorithm. RF-PWV intra-session coefficient of variation was 7.3%. At baseline, mean CR-PWV and RF-PWV were respectively of 8.21 ± 1.44 m/sec and 4.65 ± 1.42m/sec. After NTG, CR-PWV decreased (7.75 ± 1.32 m/s) and RF-PWV increased (6.75 ± 2.58 m/s), both significantly (p&lt;0.01). However, stiffness of the whole upper limb (carotid-finger PWV) did not change significantly (7.37 ± 0.87 m/s vs 7.29 ± 1.08 m/s, p=0.605). Conclusions: This first attempt to measure regional stiffness of small arteries shows that it is possible to measure hand PWV. Again, we observed opposite changes in regional stiffness of different vascular territories with a vasodilator drug. These results may open up the path to a better understanding of microcirculation consequences of an altered stiffness gradient.

THE IMPACT OF ANTIHYPERTENSIVE DRUGS ON VASCULAR RIGIDITY AND ON THE GRADIENTS OF ARTERIAL STIFFNESS: A PILOT STUDY

Objective: Damages to barosensitive organs would be induced by the reversal of the arterial stiffness gradient. Our team has demonstrated that administration of nitroglycerin reduces regional stiffness of muscle arteries (radial and femoral) without modifying aortic stiffness, resulting in increased aortic-brachial (AB-PWV) and aortic-femoral (AF-PWV) stiffness gradients. The aim of this project is to study the impact of antihypertensive treatment on arterial stiffness, particularly on stiffness gradients. Design and method: This pilot study was performed in 19 hypertensive patients (age: 71 ± 11 years, men: 85%). The aortic, brachial and femoral stiffnesses were respectively measured by the carotid-femoral (cf-PWV), carotid-radial (cr-PWV) and femoral-dorsalis pedis (fd-PWV) pulse wave velocity during 2 visits: with and without medication for high blood pressure. During the drug-free visit, patients were to stop taking their antihypertensive drugs 2-3 days before their assessment, depending on their condition. The AB-PWV and AF-PWV ratios were obtained by dividing cf-PWV by cr-PWV or fd-PWV respectively. Results: At the visit without antihypertensive drugs, the cf-PWV, cr-PWV and fd-PWV were respectively 12.91 ± 0.65 m/s, 9.6 ± 0.4 m/s and 10.3 ± 0.3 m/s, resulting in an AB- ratio PWV of 1.37 ± 0.09 and an AF-PWV ratio of 1.21 ± 0.07. At the visit with medication, a significant decrease in mean arterial pressure of 9.5 mmHg (p &lt; 0.001) was observed. In addition, reductions in cr-PWV of 0.79 m/s (p = 0.034) and fd-PWV of 0.45 m/s (p = 0.29) were noted, with no statistically significant change in cf-PWV (p = 0.83), leading to a non-significant increase in the AB-PWV (p = 0.21) and AF-PWV (p = 0.52) ratios. Conclusions: The preliminary data from this pilot project, although statistically non-significant, evolves in the same direction as those obtained with the administration of nitroglycerin. Indeed, there is a decrease in brachial and femoral stiffness leading to an increase in the gradients, which could have consequences for the microcirculation. These results suggest an impact of antihypertensive drugs on peripheral arteries and the vascular stiffness gradients, which could be confirmed with the continuation of this project on a larger sample.

Analysis of the use of nitroglycerin in pre-hospital procedure by medical rescue teams in patients with acute coronary syndrome (ACS STEMI), with particular regard to a closed right coronary artery

Introduction: Currently, cardiological societies and associations do not recommend the use of nitroglycerin in patients with acute coronary syndrome ST-elevation myocardial infarction (ACS STEMI). However, an analysis of medical rescue practice shows that this medicine is still being used. The aim of this study is to conduct a correlation analysis of the use of nitroglycerin by medical rescue teams (MRT) in patients with ACS STEMI and its impact on selected biochemical parameters. Materials and methods: The study group consisted of 312 patients. Data for these patients over a period of 8 years (2009–2017) was analysed. A retrospective study of the dispatch orders for MRT, including primary transport was conducted. Results: Coronary angiography revealed a closed right coronary artery (RCA) in 312 patients. In 210 patients, the MRT administered nitroglycerin during pre-hospital procedure, where RCA closure was confirmed in a coronary angiography. After administering nitroglycerin and discovering an RCA occlusion, more favourable results of biochemical parameters and statistical differences between the groups in Killip class were shown (p = 0.022). Lower values of Troponin I and creatine kinase–myocardial band (CK-MB) max. parameters as well as higher cardiac ejection fraction (left ventricular ejection fraction – LVEF) were observed after administering nitroglycerin (no statistical significance). Conclusions: It was not clearly demonstrated that the use or non-use of nitroglycerin at the pre-hospital stage (1–2 doses of the drug) negatively affected the patient’s condition. At the same time, it was shown that the use of nitroglycerin at the pre-hospital stage, and the lack of nitroglycerin administration at hospital resulted in lower, selected biochemical parameters, and that theuse of nitroglycerin had a significant impact on the Killip class.

CASE OF CORONARY ARTERY SPASM WITH FATAL OUTCOME IN THE EARLY PERIOD AFTER PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY OF THE RIGHT CORONARY ARTERY WITH IMPLANTATION OF BARE METAL STENTS

The paper presents a clinical case of coronary artery spasm after implantation of bare metal stents. The 60-year-old man was admitted to the hospital with the progression of the coronary heart disease and high angina pectoris functional class for coronary angiography. The patient had the main predisposing factor for the development of coronary artery spasm, which is 20-year smoking history. Based on the results of the coronary angiography, the decision was made to conduct endovascular treatment. The patient was discharged on the 2 nd day after angioplasty with implantation of two stents in the right coronary artery. On the evening of discharge, the man developed a severe pain attack in the epigastric region and turned to the hospital. The electrocardiogram revealed ST-segment elevation in leads II, III, aVF, T-waves were negative in leads I, aVL and V3-6. Repeat coronary angiography showed the stent implantation sites were passable, there was a pronounced diffuse coronary artery spasm, which could not be eliminated by intracoronary administration of nitroglycerin. Coronary artery spasm induced by coronary angioplasty with stent placement is a rare complication that can develop at different time intervals after endovascular intervention. Based on the presented clinical case, it appears likely that even after bare metal stents implantation, the development of endovascular dysfunction leading to coronary spasm is possible.

Comprehensive clinical phenotyping of nitroglycerin infusion induced cluster headache attacks.

BackgroundNitroglycerin administration allows the study of cluster headache attacks in their entirety in a standardised way.MethodsA single-blind, placebo-controlled, cross-over study using weight-calculated intravenous nitroglycerin administration at 0.5 µg/kg/min over 20 minutes to study cluster headache attacks, including accompanying non-headache symptoms and cranial autonomic symptoms.ResultsThirty-three subjects with cluster headache were included in the study; 24 completed all three study visits. Nitroglycerin-induced attacks developed in 26 out of 33 subjects (79%) receiving unblinded nitroglycerin infusion, and in 19 out of 25 subjects (76%) receiving single-blinded nitroglycerin infusion, compared with one out of 24 subjects (4%) receiving single-blinded placebo infusion. Episodic cluster headache subjects had a shorter latency period to a nitroglycerin-induced attack compared to the chronic cluster headache (CCH) subjects (U = 15, z = −2.399, p = 0.016). Sixteen of nineteen episodic cluster headache (mean, 84%; 95% confidence interval, 66–100%) and 11 of 14 chronic cluster headache subjects developed a nitroglycerin-induced attack (79%, 54–100%) following the unblinded nitroglycerin infusion. Following the single-blinded nitroglycerin infusion, eight out of 13 episodic cluster headache (62%, 31–92%) and 11 out of 12 chronic cluster headache (92%, 73–100%) subjects developed nitroglycerin-induced attacks. Nitroglycerin induced non-headache symptoms in the majority of subjects receiving it: 91% in the open unblinded nitroglycerin visit and 84% in the single-blinded nitroglycerin visits, compared with 33% in the single-blinded placebo visit. Cranial autonomic symptoms were induced by nitroglycerin infusion, 94% in the open unblinded nitroglycerin visit and 84% in the single-blinded nitroglycerin visit, compared with 17% in the single-blinded placebo visit.ConclusionIntravenous weight-adjusted nitroglycerin administration in both episodic cluster headache in bout and chronic cluster headache is effective and reliable in inducing cluster headache attacks, cranial autonomic symptoms and non-headache symptoms.