Intravenous Nitroglycerin Research Articles

Word of caution: clinical apparent coronary spasm following pulsed field cavotricuspid isthmus ablation despite nitroglycerin prophylaxis

Structured Abstract Background Pulsed field ablation (PFA) is a novel ablation technology. A rare side-effect is the occurrence of mostly subclinical coronary spasms when PF-energy is applied in proximity to coronary arteries. However, it has been described that prior application of nitroglycerin attenuates these effects. Case summary A 75-year old female underwent catheter ablation with a penta-spline PFA-catheter. After pulmonary vein isolation, the PFA-catheter was positioned on the cavotricuspid-isthmus(CTI). Before ablation, 2mg of nitroglycerin were administered intravenously. After 10 PFA applications the CTI was successfully blocked. After a timely delay of 95 seconds, a clinical apparent vasospasm with ST-elevations in leads II, III, aVF on the ECG was noticed. Shortly thereafter the clinical course was aggravated by hemodynamically-relevant non-sustained ventricular tachycardias (nsVT) followed by asystole, requiring pacing and additional 4mg of nitroglycerin. Twelve minutes later, a stable sinus rhythm with normalized ST-segments was restored. The spasm resolved without any sequelae. Post-procedural coronary angiogram showed right-dominant coronary circulation. Discussion This is the first report of a timely-delayed, clinical apparent coronary spasm with a presentation of hemodynamically relevant nsVT and asystole despite prophylactic application of high-dose intravenous nitroglycerin prior to PFA along the CTI. Subclinical vasospasm during PFA at the CTI has been described before. Severe spasms could be prevented by nitroglycerin. A word of caution needs to be raised as prophylactic nitroglycerin did not prevent the hemodynamically relevant coronary spasm in the here reported patient. Until now, it remains unclear how much later such effects may occur, therefore patients should be monitored closely.

Early severe paravalvular leak following mitral valve replacement with a prosthetic mechanical bileaflet valve

Abstract: A middle-aged woman developed severe breathlessness soon after mitral valve replacement for rheumatic heart disease with severe mitral stenosis and moderate mitral regurgitation. Echocardiography (two-dimensional and transesophageal) revealed a severe paravalvular leak into the left atrium between the mechanical bileaflet mitral valve and the aortic annulus. The patient was stabilized with intravenous nitroglycerin and torsemide, and the heart rate was controlled with tablet metoprolol. The patient was successfully treated with a redo surgery using a larger mechanical mitral bileaflet valve (size 29 mm) and interrupted sutures. A 25-mm mechanical bileaflet valve was used during index surgery.

The HEARTRISK6 Scale: Predicting Short-Term Serious Outcomes in Emergency Department Acute Heart Failure Patients

BackgroundAcute heart failure (AHF) is a common emergency department (ED) presentation that may have poor outcomes but often does not require hospital admission. There is little evidence to guide dispositional decisions. ObjectivesThe authors sought to create a risk score for predicting short-term serious outcomes (SSO) in patients with AHF. MethodsWe pooled data from 3 prospective cohorts: 2 published studies and 1 new cohort. The 3 cohorts prospectively enrolled patients who required treatment for AHF at 10 tertiary care hospital EDs. The primary outcome was SSO, defined as death <30 days, intubation or noninvasive ventilation (NIV), myocardial infarction, or relapse to ED <14 days. The logistic regression model evaluated 13 predictors, used an AIC-based step-down procedure, and bootstrapped internal validation. ResultsOf the 2,246 patients in the 3 cohorts (N = 559; 1,100; 587), the mean age was 77.4 years, 54.5% were male, 3.1% received intravenous nitroglycerin, 5.2% received ED NIV, and 48.6% were admitted to the hospital. There were 281 (12.5%) SSOs including 70 deaths (3.1%) with many in discharged patients. The final HEARTRISK6 Scale included 6 variables: valvular heart disease, tachycardia, need for NIV, creatinine, troponin, and failed reassessment (walk test). Choosing HEARTRISK6 total-point admission thresholds of ≥1 or ≥2 would yield, respectively, sensitivities of 88.3% (95% CI: 83.9%-91.8%) and 71.5% (95% CI: 65.9%-76.7%) and specificities of 24.7% (95% CI: 22.8%-26.7%) and 50.1% (95% CI: 47.9%-52.4%) for SSO. ConclusionsUsing 3 large prospectively collected datasets, we created a concise and sensitive risk scale for patients with AHF in the ED. Implementation of the HEARTRISK6 scale could lead to safer and more efficient disposition decisions.

Nurses’ knowledge of intravenous nitroglycerine injection: a survey study

Nurses’ knowledge of intravenous nitroglycerine injection: a survey study

RIGHT VENTRICULAR DYSFUNCTION AND TRICUSPID VALVE SURGICAL CORRECTION: ROOM FOR STRESS ECHOCARDIOGRAPHY?

Abstract We report the case of a 50–years–old young woman with multi–operated rheumatic valvular heart disease; aortic, mitral, and tricuspid commissurotomy (1994); aortic valve replacement with bioprosthesis for endocarditis (1998); mitro–aortic replacement with mechanical prosthesis and tricuspid valve plastic repair (1999); mitral valve replacement and re–do of tricuspid plastic repair (2003). Concomitant conduction pathway disease (BAV II type 1 and RBB). The patient was admitted in June 2023 for wet &amp; warm NYHA IV right heart failure with severe peripheral congestion and ascites. On echocardiography: LV with systo–diastolic compression, EF 51%; normo–functioning aortic prosthesis; dilated (TDA 24 cm2), hypokinetic (TAPSE 9mm,S‘ 4 cm/s,FAC 25%) right ventricole (RV), with poor load adaptation (load adaptation index 16, RVCPI 108 mm*mmHg, ePAPI 1.1); torrential IT, caval plethora with systolization of hepatic venous flow. Medical therapy was initiated with intravenous bolus diuretics, nitroglycerin and inotropic support (dobutamine 2.5 y). In order to define the best therapeutic strategy in the persistence of torrential IT and RV dysfunction we performed: trans–oesophageal echocardiography, showed massive IT from ring dilatation and wide flail of the septal flap not suitable for edge–to–edge correction, total–body angioTC, with no relevant findings, right cardiac catheterization, which documented pulmonary pressure and arteriolar resistances within limits (wedge 12 mmHg,PAP25/15/18 mmHg,RAP 11 mmHg,PAPI 0. 9,RVSWI 4.8) with reduced cardiac index (2.14 l/min/cm2) and stress–echocardiography with dobutamine that showed presence of RV contractile reserve (FAC 28%&amp;gt;39%). In consideration of the functional properties of the tricuspid valve, absence of pulmonary hypertension and given the presence of RV contractile reserve, patient underwent tricuspid valve replacement surgery with a bioprosthesis (SJ Epic 27 mm) in mini–thoracotomy with smooth postoperative course. At 3 months follow–up showed functional recovery (NYHA II), with good prosthetic function and partial reverse remodeling of the RV (TDA 14 cm2, FAC of 30%). In conclusion, by documenting right ventricular contractile reserve, stress echocardiography proved to be an important aid in predicting absence of RV failure in the immediate post–surgical period, presenting attractive prospects in the assessment of RV functional reserve in patients undergoing to corrective tricuspidal surgery.

Abstract 2099: Coronary Artery Thrombosis Due To Intramural Hematoma

BJMC ,male 61 years old, presented with acute chest pain and non ST acute myocardial infarction. ECG showed ST segment depression on anterior and lateral precordial leads and ST elevation on aVR. Ultra-sensitive Troponin T rised . Coronary angiography showed calcified Left main(LM) with critical lesion extending to anterior descending artery. Percutaneous Coronary Intervention (PCI) was performed succesfully with stent implantation. Two hours later he started with epigastric discomfort , anxiety ,chest pain , diaphoresis , tachycardia and acute ECG changes , irresponsive to intravenous nitroglycerin . He evolved to ventricular tachycardia and cardiac arrest , with CPR. New PCI was followed with immediate clinical improvement . Clinical symptoms of ischemia and hemodynamic instability were due to significant (LM) caliber reduction .IMH is a pathological process were blood accumulate within the media space, suggesting new stenosis or spasm. IMH is unfrequent - may occur in initial hours and even at several days after apparently succesfull intervention. IMH causes acute lumen obstruction and thrombosis. The diagnosis is frequently missed and the clinical course can be dramatic and life threatening. Intravascular ultrasound (IVUS) is a very importante tool to identify IMH and should be available in complex cases interventions.

Rapid Intravenous Glyceryl Trinitrate in Ischemic Damage (RIGID): A potential neuroprotection strategy for acute ischemic stroke (AIS) patients

Despite advances in intravenous thrombolysis and endovascular thrombectomy, numerous acute ischemic stroke survivors continue to experience various disability levels. The nitric oxide (NO) donor, Glyceryl Trinitrate (GTN), has been identified as a potential neuroprotective agent against ischemic damage. We evaluated the safety and feasibility of intravenous GTN in AIS patients. Subsequently, we conducted a secondary analysis to assess for possible efficacy of GTN as a neuroprotectant. We conducted a prospective, double-blind, randomized controlled trial in the Stroke Intervention & Translational Center (SITC) in Beijing Luhe Hospital, Capital Medical University (ChiCTR2100046271). AIS patients within 24 h of stroke onset were evenly divided into GTN or control groups (n = 20 each). The GTN group received intravenous GTN (5 mg in 50 ml saline at a rate of 0.4 mg/h for 12.5 h/day over 2 days), while controls were administered an equivalent volume of 0.9% saline. Both groups followed standard Stroke Guidelines for treatment. Safety measures focused on SBP<110 mmHg and headache occurrence. Efficacy was assessed via the 90-day modified rankin score (mRS) and the national institutes of health stroke score (NIHSS). Of the 40 AIS patients, baseline characteristics such as age, gender, risk factors, and pre-mRS scores showed no significant difference between the groups. Safety measures of SBP<110 mmHg and headache occurrence were comparable. Overall, 90-day mRS (1 vs. 1) and NIHSS (1 vs. 1) did not significantly differ between groups. However, the GTN-treated group had a benefit in enhancing NIHSS recovery (△NIHSS 4.5 vs. 3, p = 0.028), indicating that GTN may augment recovery. Subgroup analyses revealed a benefit in the GTN group at the 90-day NIHSS score and △NIHSS follow up for non-thrombolysis patients (1 vs. 2, p = 0.016; 5 vs. 2, p = 0.001). Moreover, the GTN group may benefit mild stroke patients in NIHSS score at 90 day and △NIHSS observed at 90 days (1 vs. 1, p = 0.025; 3 vs. 2 p = 0.002). Overall, while preliminary data suggest GTN might aid recovery in NIHSS improvement, the evidence is tempered due to sample size limitations. The RIGID study confirms the safety and feasibility of intravenous GTN administration for AIS patients. Preliminary data also suggest that the GTN group may provide improvement in NIHSS recovery compared to the control group. Furthermore, a potential benefit for non-thrombolysis patients and those with mild stroke symptoms was identified, suggesting a possible potential role as a tailored intervention in specific AIS subgroups. Due to the limited sample size, further larger RCT will be necessary to replicate these results. Trial Registrationwww.chictr.org.cn, identifier: ChiCTR2100046271.

Abstract TMP31: Rapid Intravenous Glyceryl Trinitrate in Ischemic Damage (RIGID): A Potential Neuroprotection Strategy for Acute Ischemic Stroke (AIS) Patients

Background: Despite advances in intravenous thrombolysis and endovascular thrombectomy, numerous acute ischemic stroke survivors continue to experience various disability levels. The nitric oxide (NO) donor, Glyceryl Trinitrate (GTN), has been identified as a potential neuroprotective agent against ischemic damage. This study evaluates the safety and preliminary efficacy of intravenous GTN administration in AIS patients. Methods: We conducted a prospective, double-blind, randomized controlled trial at Beijing Luhe Stroke Center (ChiCTR2100046271). AIS patients within 24 hours of onset were evenly divided into GTN or control groups (n=20 each). The GTN group received intravenous GTN (5 mg in 50 ml saline at a rate of 0.4 mg/h for 12.5 h/day over 2 days), while controls were administered an equivalent volume of 0.9% saline. Both groups followed standard Stroke Guidelines for treatment. Safety measures focused on SBP&lt;110mmHg and headache occurrence. Efficacy was assessed via the 90-day modified rankin scale (mRS) and the national institutes of health stroke scale (NIHSS) scores. Results: Of the 40 AIS patients, baseline characteristics such as age, gender, risk factors, and mRS scores showed no significant difference between the groups. Safety measures of SBP&lt;110mmHg and headache occurrence were also comparable. Overall, 90-day mRS(1 vs 1) and NIHSS (1 vs1 )did not significantly differ between groups. However, the GTN-treated group showed a superior NIHSS recovery (ΔNIHSS 4.5 Vs 3, p=0.028), indicating that GTN can well-allow patients to recover within the same time frame. Subgroup analyses revealed a noteworthy benefit of GTN in the 90-day NIHSS score for non-thrombolysis patients (1 vs 2, p=0.016). Moreover, GTN benefited mild stroke patients (NIHSS score &lt;6) at 90 days (p=0.025). Conclusion: The RIGID study confirms the safety of intravenous GTN for AIS patients. Notably, while overall 90-day mRS and NIHSS scores between the GTN and control groups did not significantly vary, the GTN group displayed a pronounced improvement in NIHSS recovery. Additionally, GTN demonstrated particular efficacy for non-thrombolysis patients and those with mild stroke symptoms, suggesting its potential as a tailored intervention in specific AIS subgroups.

High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial

ObjectivesSympathetic crashing acute pulmonary edema (SCAPE) is a subset of heart failure with a dramatic presentation. The unique physiology of this condition requires a different management strategy from the conventional...

Safety of prehospital intravenous bolus dose nitroglycerin in patients with acute pulmonary edema: A 4-year review.

Intravenous nitrates are a primary therapy for hypertensive congestive heart failure (CHF) with acute pulmonary edema (APE) in the hospital setting. Historically, sublingual nitrates are the mainstay of emergency medical services (EMS) pharmacologic therapy for these patients. We aimed to evaluate the safety of prehospital bolus dose intravenous nitroglycerin in patients with APE. This is a retrospective evaluation of EMS data between March 15, 2018, and March 15, 2022, where CHF with APE was suspected and bolus-dose intravenous nitroglycerin was administered. Protocol inclusion criteria were hypertension (systolic blood pressure [SBP]>160mmHg) and acute respiratory distress, with a presumption of decompensated CHF with APE. These patients received 1mg intravenous nitroglycerin, with the option to repeat once for ongoing distress if the SBP remained>160mmHg. The primary outcomes were adverse events, defined as hypotension (SBP<90mmHg), syncope, vomiting, or dysrhythmia. The final analysis included 235 patients. In patients receiving intravenous bolus nitroglycerin, the median (interquartile range [IQR]) initial and final EMS SBP values decreased from 198mmHg (180-218) to 168 (148-187), respectively. The median (IQR) pulse decreased from 108 (92-125) to 103 (86-119), and the median oxygen saturation increased from 89% (82-95) to 98% (96-99). Three episodes (1.3%) of asymptomatic hypotension occurred, and none required intervention. This study supports a favorable safety profile for prehospital bolus-dose intravenous nitroglycerin for decompensated CHF with APE. Blood pressure, heart rate, and oxygen saturation improvements are also demonstrated. Further, prospective studies are needed to confirm these findings.

Abstract 19084: The Deadly Squeeze - Coronary Vasospasm Complicated by Myocardial Infarction and Cardiac Arrest

Introduction: Acute coronary syndrome (ACS) typically results from atherosclerotic plaque rupture. However, about 6% of ST elevation Myocardial Infarction (STEMI) patients have no obstructive disease. We present a case of STEMI, diagnosed with coronary vasospasm. Hypothesis: Methods: A 54-year-old female with alcohol abuse, smoking and uncontrolled hypertension presented after an out of hospital ventricular fibrillation cardiac arrest. EKG showed anterolateral ST elevation (STE). Left heart catheterization (LHC) showed moderate to severe multi-vessel disease without a definitive culprit lesion. STE resolved. Heart team approach for revascularization was contemplated. Echocardiogram showed systolic dysfunction with ejection fraction (EF) of 25%. Patient had another cardiac arrest and EKG showed recurrent anterolateral STE. Repeat LHC showed severe vasospasm of Left anterior descending (LAD) artery and diagonal branch, which improved with intracoronary (IC) nitroglycerin. Vasospasm was attributed to smoking and catecholamine excess from alcohol withdrawal. She was started on intravenous nitroglycerin and amlodipine. Her hospital course was complicated by high degree AV block requiring temporary pacer. She was eventually extubated with good neurological recovery and recovered systolic function (EF 60%). She was counselled on smoking and alcohol cessation and discharged home on isosorbide dinitrate and Amlodipine with planned surgical revascularization. Results: Coronary vasospasm (CVS) can occur both in normal and diseased coronaries. Risk factors include smoking, alcohol use and withdrawal, cocaine, mental stress, etc. Vasospasm may present as Prinzmetal’s angina, myocardial infarction, AV block, or fatal arrhythmias. IC nitroglycerine during LHC aids in diagnosis of CVS in setting of ACS. IVUS (Intravascular ultrasound) may help diagnose presence or absence of concomitant atherosclerotic disease. Provocative testing with IC ergonovine and acetylcholine may be considered in non-ACS setting. Conclusions: This case emphasizes the need to have a high index of suspicion for vasospasm to prevent associated complications and establish an accurate diagnosis and guide proper management of this potentially fatal disease.

Flash pulmonary edema in the cardiac catheterization laboratory: a case report

Flash pulmonary edema is a potentially fatal condition that can suddenly deteriorate a patient's status in a variety of settings, including the catheterization laboratory. We describe a 51-year-old woman with a history of hypertension who was admitted for a second valve operation for degenerated aortic bioprosthesis. Before undergoing coronary angiography, she looked a little worried, she experienced respiratory distress and a significant increase in blood pressure in favor of acute flash pulmonary edema, which was immediately and successfully managed by respiratory support and administration of high-dose intravenous nitroglycerine and loop diuretic therapy. The present scenario highlights the significance of being aware of the warning signs of acute flash pulmonary edema to make a prompt diagnosis and initiate the appropriate treatment to prevent catastrophic consequences.

Controlled Hypotension During Functional Endoscopic Sinus Surgery (FESS) - A Comparative Evaluation Between Esmolol and Nitroglycerine

Background: Intraoperative bleeding is a frequent complication in functional endoscopic sinus surgery (FESS). Controlled hypotension is a useful technique for enhancing the surgical field and reducing operative blood loss. Nitrovasodilators and beta receptor antagonists are effective options for regulated hypotensive anaesthesia during FESS. We assessed the efficacy of esmolol and nitroglycerine for controlled hypotension in subjects undergoing FESS. Methods: A source of 64 participants undergoing elective FESS, were randomly allocated to group N (n=32), which got an intravenous Nitroglycerin infusion at 5–10 µg/kg/min, and group E (n=32), which received an initial bolus of 500 mcg/kg of intravenous esmolol over 30 seconds. Hemodynamic parameters were measured and the visibility of the surgical field was assessed using the average category scale (ACS). Result: In groups N and E, the mean surgical duration was 113.5 minutes and 102.34 minutes, respectively, and the mean operative blood loss was 188.5 ml and 173.7 ml. The esmolol group experienced a rapid decline in heart rate, and there was a statistically significant difference in mean SBP, DBP, and MAP across the study groups. At the 10-min, the majority of cases displayed scores of 3 in group E and 4 in group N. In the esmolol group, there was a significant difference between the hypotensive phase and the hemodynamic measures (p&lt;0.05). Conclusion: Nitroglycerine and esmolol were effective in controlling hypotension. However, esmolol was superior in controlling the operative bleeding, surgical duration, enhanced surgical field visibility, and absence of reflex tachycardia compared to nitroglycerine

High-Dose Nitroglycerin Bolus and Non-Invasive Ventilation Prevent Intubation or ICU Admission on Hypertensive Emergency and Acute Pulmonary Edema: Sympathetic Crashing Acute Pulmonary Edema (SCAPE) Treatment on STEMI Patient: A Case Report

Highlight: 1. SCAPE could lead to respiratory failure when not treated promptly. 2. High-dose NTG and NIV support can be used as an alternative treatment to overcome hypertensive emergency and pulmonary edema, thus preventing the need for endotracheal intubation and ICU admission. - Background: A marked elevation in blood pressure that causes acute heart failure and fluid accumulation in the lungs is known as sympathetic crashing acute pulmonary edema (SCAPE). Here, we present a SCAPE patient with severe respiratory failure who was successfully treated with high-dose nitroglycerin (NTG) bolus and non-invasive ventilation (NIV). Case summary: A 48-year-old male was referred to our center with typical chest pain and dyspnea. Physical and additional examination found hypertensive emergency (196/66 mmHg), acute pulmonary edema, and acute heart failure, accompanied by anterior STEMI and severe respiratory failure (P/F ratio of 72) in need of intubation. He was given 2 mg intravenous NTG bolus twice supported with NIV, diuretics followed by the primary percutaneous coronary intervention (PCI) stenting in mid left anterior descending (LAD). The patient recovered from acute pulmonary edema, and the P/F ratio improved from 72 to 321 without intubation. Discussion: SCAPE could lead to respiratory failure requiring intubation and intensive care unit (ICU) admission when not treated promptly. The administration of large doses of NTG and NIV was safe and resulted in a speedy improvement in symptoms. Conclusion: SCAPE can be resolved without invasive procedures, using high-dose NTG and NIV support to overcome hypertensive emergency and pulmonary edema.

The human NTG model of migraine in drug discovery and development

ABSTRACT Introduction Various triggers can originate a migraine attack. In healthy volunteers and patients with migraine, the nitroglycerin (NTG) provocation model induces a headache that resembles migraine in pain characteristics and vascular manifestations. This headache is reversible and treatable in monitored conditions, providing an opportunity to test novel antimigraine medications in early clinical development. Areas covered This perspective covers the main characteristics and applications of the human NTG model of migraine with effective and ineffective antimigraine therapies. Expert opinion The NTG model represents a potential de-risking strategy to test novel hypotheses for antimigraine mechanisms in humans. Considering previous studies conducted with effective and ineffective antimigraine therapies, the sensitivity of the model was 71% while the specificity was 100%. The probability that following an analgesic effect, that compound would truly be efficacious in individuals with migraine was 100%. Following a negative result, the probability that such compound would truly be ineffective in patients with individuals was 33%. A clinical trial testing the analgesic properties of novel compounds after a sublingual and/or intravenous NTG challenge in migraine patients may support a subsequent phase 2 trial for the treatment of migraine.

Acute Pulmonary Edema and NSTEMI.

Emergency medicine residents and medical students on emergency medicine rotation. Acute pulmonary edema is a common and potentially fatal presentation in the emergency department. More than 1 million patients are admitted annually with a diagnosis of pulmonary edema secondary to cardiac causes.1 Pulmonary edema is broadly split into two main categories: cardiogenic and noncardiogenic. Cardiogenic pulmonary edema is characterized by acute dyspnea caused by the accumulation of fluid within the lung's interstitial and/or alveolar spaces, which is the result of acutely elevated cardiac filling pressures.2 Noncardiogenic pulmonary edema is characterized by fluid accumulation within the alveolar space in the absence of elevated pulmonary capillary wedge pressure.2 These patients often present critically ill, and rapid identification and aggressive management is paramount in caring for patients with pulmonary edema. Dyspnea is the most common presentation with a sensitivity of 89% but a low specificity of 51%.3 Workup of pulmonary edema often includes laboratory testing, electrocardiogram (EKG), chest x-ray (CXR), and often bedside ultrasound (US) and echocardiography.4 Pulmonary edema management depends on the etiology but is often focused on preload and afterload reduction. Diuretics, nitrates, and optimizing ventilatory support through non-invasive and invasive strategies are the mainstay of treatment. At the end of this practice oral boards case, the learner will:1) recognize unstable vital signs (VS) and intervene to stabilize ventilation and oxygenation, 2) demonstrate the ability to obtain a complete medical history including the important characteristics of chest pain, 3) demonstrate an appropriate exam on a patient, 4) order the appropriate evaluation studies for a patient with complaints of dyspnea, 5) interpret the results of diagnostic evaluation and diagnose Non- ST elevation myocardial infarction (NSTEMI) and pulmonary edema, 6) order appropriate management of pulmonary edema and NSTEMI, and 6) demonstrate effective communication with patient and family members. Practice oral boards. Immediate Feedback was solicited from the learners and observers participating in the case both by verbal discussion and completion of a rating for the case following the debriefing. The efficacy of the educational content was assessed by comparing scoring measures across residents based on the training year. Scoring measures of the American College of Graduate Medical Education (ACGME) core competencies were performed using a scale from 1 - 8, 1-4 being unacceptable performance and 5 - 8 being acceptable. Efficacy was assumed based on full completion of the case by the residents who acted as practice oral board candidates, and a debriefing session followed to discuss the key components of the case. This case was presented to twelve Emergency Medicine Residents, seven PGY 1 and five PGY 2 at a relatively new residency program. The overall average score for the residents was 5.62. The PGY 1 Residents' average on the case was 5.56, and the average for the PGY 2 Residents was slightly better at 5.70. The slight improvement noted by the PGY 2 Residents is likely attributable to more clinical experience; however, both classes did not have any prior exposure to the oral board format until this simulated experience. Six residents completed all critical actions in the case. Of those who missed a critical action, failing to diagnose NSTEMI and consulting cardiology were the most common. All learners found educational value in the case with an overall rating of 4.83 (1-5 Likert scale, 5 being excellent). Acute pulmonary edema and NSTEMI are common diagnoses that will be frequently encountered for most emergency physicians. This case highlights the need for early identification and aggressive management of the patient presenting with respiratory distress. The differential for respiratory distress is large, but most learners were able to quickly identify pulmonary edema based on the exam findings of jugular vein distention (JVD), rales, and lower extremity edema. Most learners quickly escalated to a non-rebreather mask and ultimately to BPAP (bilevel positive airway pressure) without requesting to intubate the patient. There was notable variation in the approach to administering nitrates, but most ordered an intravenous (IV) nitroglycerin (NTG) drip and requested pharmacy assistance in dosing. Diuretics were ordered by all the learners, but some were hesitant to start early because they felt the effect would be delayed. Some of the residents did not identify ischemic changes on the EKG at first glance but did request to review a second time when the troponin result was positive. All residents gave aspirin after noting the positive troponin, but not all were able to make a clear diagnosis of NSTEMI or consult cardiology. Although the case was relatively straightforward, residents enjoyed early diagnosis and aggressive management of the patient with impending respiratory failure. Many residents are asking for an ultrasound early in the workup of this patient presenting in respiratory distress. Although not a critical action in this case, it highlights the emphasis placed on ultrasonography in the current emergency medicine curriculum. Pulmonary Edema, Cardiovascular emergencies, NSTEMI.

Focal pulsed field ablation and ultrahigh-density mapping — versatile tools for all atrial arrhythmias? Initial procedural experiences

BackgroundFocal pulsed field ablation (FPFA) is a novel and promising method of cardiac ablation. The aim of this study was to report the feasibility, short-term safety, and procedural findings for a broad spectrum of ablated atrial arrhythmias.MethodsPatients (n = 51) scheduled for ablation of atrial arrhythmias were prospectively included and underwent FPFA using the Galvanize CENTAURI generator with energy delivery through commercially available ablation catheters with ultrahigh-density (UHDx) 3D electroanatomic voltage/local activation time map evaluations. Workflow, procedural data, and peri-procedural technical errors and complications are described.ResultsPlanned ablation strategy was achieved with FPFA-only in 48/51 (94%) of the cases. Ablation strategy was first-time pulmonary vein isolation (PVI) in 17/51 (36%), repeat ablation in 18/51 (38%), PVI + in 13/51 (28%), and cavotricuspid isthmus block (CTI)-only in 3/51 (6%). The mean procedure time was 104 ± 31 min (first-time PVI), 114 ± 26 min (repeat procedure), 152 ± 36 min (PVI +), and 62 ± 17 min (CTI). Mean UHDx mapping time to assess lesion formation and block after ablation was 7 ± 4 min with 5485 ± 4809 points. First pass acute (linear) isolation with bidirectional block for anatomical lesion sets was 120/124 (97%) for all PVs, 17/17 (100%) for (any) isthmus, and 14/17 (82%) for left atrium posterior wall (LAPW). We observed several time-consuming integration errors with the used ablation system (mean 3.4 ± 3.7 errors/procedure), one transient inferior ST elevation when ablating CTI resolved by intravenous nitroglycerine and one transient AV block requiring temporary pacing for > 24 h.ConclusionsFPFA was a highly versatile method to treat atrial arrhythmias with high first-pass efficiency. UHDx revealed acute homogenous low-voltage lesions in ablated areas. More data is needed to establish lesion durability and limitations of FPFA.

PO-04-005 LEFT CIRCUMFLEX ARTERY VASOSPASM DURING PULSED FIELD ABLATION AT THE MITRAL ISTHMUS: CHARACTERIZATION OF TIME-TO-RESOLUTION

While pulsed field ablation (PFA) has emerged as a novel energy modality for ablation of atrial arrhythmias and is accompanied by a theoretically safer profile given its tissue selectivity and sparing of collateral structures, a recent study has highlighted the occurrence of subtotal coronary vasospasm during atrial fibrillation (AF) ablation on the cavo-tricuspid isthmus with PFA. While these observations were subclinical, there is at least one case report of left circumflex (LCx) coronary artery vasospasm during PFA at the mitral isthmus (MI) during AF ablation. To evaluate the natural history time-to-resolution of coronary vasospasm of the LCx artery during PFA at the MI. In a prospective, consecutively enrolled cohort of patients receiving AF ablation under deep sedation, diagnostic coronary angiography was performed via right femoral arterial access before, during, and after ablation on the MI with a multi-spline PFA catheter (Farawave, Boston Scientific Inc). LCx spasm was identified, characterized by severity, and monitored for progression and time-to-resolution. A total of 19 patients underwent PFA on the lateral MI with successful bidirectional block. Notably, 7 patients (37%) developed LCx vasospasm during ablation, of which 3 cases were mild (<50% decrease in luminal diameter), 2 were moderate (50 to 90% decrease), and 2 were severe (>90% decrease). All of the mild and moderate spasm occurrences self-resolved, with mild spasm taking on average 5.7 minutes to be relieved, and moderate spasm requiring 5 minutes. Relief of severe spasm required an average of 15 minutes, with both necessitating administration of intracoronary or intravenous nitroglycerin. Electrocardiographic ST changes were only present in one case of severe spasm (which resolved with relief of spasm), and there were no hemodynamic changes during spasm. As PFA becomes an alternative to radiofrequency and cryothermal ablation, it behooves operators to be vigilant for vasospastic effects on adjacent coronary vessels during ablation. Further investigation with larger populations is required to more fully elucidate the injurious potential of PFA-induced coronary vasospasm. This study is one of the first to elaborate on the features of LCx vasospasm during PFA on the MI.Tabled 1Patient CharacteristicsAge, mean±SD, y65.6±10.1Male, n (%)14 (74)Body mass index, mean±SD30.3±4.9Medical HistoryType of atrial fibrillationParoxysmal, n (%)4 (21)Persistent, n (%)15 (79)Duration of atrial fibrillation, mean±SD, months48.2±66.4CHA2DS2-VASc Score, mean±SD2.1±1.4Hypertension, n (%)13 (68)Diabetes, n (%)4 (21)Dyslipidemia, n (%)11 (58)Sleep apnea, n (%)1 (5)Prior stroke or transient ischemic attack, n (%)2 (11)Coronary artery disease, (%)4 (21)Congestive heart failure, n (%)1 (5)Left ventricular ejection fraction, mean±SD, %62.3±3.4Left atrium dimension, mean±SD, mm45.8±9.2MedicationsWarfarin, n (%)12 (63)Non-Warfarin oral anticoagulant, n (%)7 (37)Antiarrhythmic drugs, n (%)Class I7 (37)Class II11 (58)Class III5 (26)Class IV0 (0) Open table in a new tab

Managing Patients With Sympathetic Crashing Acute Pulmonary Edema (SCAPE) Using the SCAPE Treatment Protocol: A Case Series.

Pulmonary edema refers to the accumulation of excessive fluid in the alveolar walls and alveolar spaces of the lungs. It is a life-threatening condition with a high mortality rate and requires immediate assessment and management. Use of intravenous nitroglycerin has been advocated for such cases. The authors present a case series of 3 patients who presented to the emergency department with sympathetic crashing acute pulmonary edema (SCAPE) and were managed with high-dose intravenous nitroglycerin and bilevel positive airway pressure support using the SCAPE treatment protocol, leading to early correction of blood pressure, avoidance of endotracheal intubation, and no episodes of hypotension or rebound hypertension. The authors recommend emergency physicians utilize the SCAPE treatment protocol while managing patients with SCAPE.

PACAP-PAC1 receptor inhibition is effective in opioid induced hyperalgesia and medication overuse headache models

Opioids prescribed for pain and migraine can produce opioid-induced hyperalgesia (OIH) or medication overuse headache (MOH). We previously demonstrated that pituitary adenylate cyclase activating polypeptide (PACAP) is upregulated in OIH and chronic migraine models. Here we determined if PACAP acts as a bridge between opioids and pain chronification. We tested PACAP-PAC1 receptor inhibition in novel models of opioid-exacerbated trigeminovascular pain. The PAC1 antagonist, M65, reversed chronic allodynia in a model which combines morphine with the migraine trigger, nitroglycerin. Chronic opioids also exacerbated cortical spreading depression, a correlate of migraine aura; and M65 inhibited this augmentation. In situ hybridization showed MOR and PACAP co-expression in trigeminal ganglia, and near complete overlap between MOR and PAC1 in the trigeminal nucleus caudalis and periaqueductal gray. PACAPergic mechanisms appear to facilitate the transition to chronic headache following opioid use, and strategies targeting this system may be particularly beneficial for OIH and MOH.