Pre-existing Cardiac Conditions Research Articles

Clozapine in a patient with treatment-resistant schizophrenia and hypertrophic cardiomyopathy: a case report.

BackgroundThere is currently limited experience in the initiation and maintenance of clozapine for treatment-resistant psychosis in adults with established structural heart disease. These complex patients require close supervision and liaison between colleagues. Here we present the successful experience of treating one such patient within our service and describe a monitoring plan to ensure that these treatments can be provided both safely and effectively.Case presentationA 36-year-old man with treatment-resistant schizophrenia and known hypertrophic cardiomyopathy (HCM) was admitted to a specialist unit for a trial of clozapine. His psychiatric illness was characterised by multimodal hallucinations and delusions combined with low mood and poor motivation. The diagnosis of HCM was made 3 years previously following a routine electrocardiogram (ECG), and he had remained asymptomatic throughout this time; there were concerns about the risk of initiating clozapine given his pre-existing cardiac condition.Baseline investigations were performed as per local guidelines prior to commencing clozapine; these were within normal limits other than a mildly raised troponin level of 54 ng/L (normal <16 ng/L), which was attributed to the HCM. In addition, baseline transthoracic echocardiography (TTE) was performed which showed no change in the structural heart disease in comparison with previous TTEs.Clozapine was started at 12.5 mg daily and up-titrated to 150 mg twice daily over 14 days as per our institute’s guidelines. The patient was monitored with regular testing of troponins, inflammatory markers and ECG. On day 18, the troponin level increased to 1371 ng/L. Creatine kinase and inflammatory markers remained stable. No changes in ECG or TTE were noted and the patient remained clinically asymptomatic.Cardiology opinion was sought and reported that the finding of an isolated elevated troponin was likely to reflect a ‘troponin leak’ in the context of increased cardiac muscle mass associated with HCM. In the absence of any clinical compromise, it was not felt to be of concern. Clozapine was continued with good effect on mental state. Troponin levels gradually reduced and the patient remained well.ConclusionsWhile multiple cases of clozapine-induced cardiotoxicity have been reported in the literature, its implications for pre-existing structural disease are unclear. This case report suggests that clozapine can be safely introduced in pre-existing HCM, explores strategies for monitoring and highlights the importance of liaising with experienced cardiologists.Declaration of interestNone.Copyright and usage© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

An autopsy approach to bolus deaths

BackgroundThe term “bolus death” or “cafe coronary” refers to a misplaced larynx or laryngeal inlet by foreign bodies, in most cases by unchewed pieces of food such as meat, sausage, or fruit. The pathophysiologic mechanism of death is still debatable – sudden reflex cardiac arrests and asphyxial suffocations are implicated. In particular, children, alcoholics, and persons with brain-related damages belong to this risk group. A defective dentition is also associated with the risk of bolus deaths. AimThe aim of the study was to supplement existing literature by evaluating cases of bolus deaths and determining the most likely mechanism of death in a large autopsy sample. MaterialAmong 31,647 autopsies, 59 cases of cafe coronary syndrome were identified and evaluated: 38 male adults and 21 female adults between the ages of 26 and 89 years. MethodsA retrospective analysis of autopsies performed in the Institutes of Forensic Medicine in Rostock (1990–2014) and Munich (1990–1999) was conducted. Autopsy findings, circumstances of death, police investigations, preexisting conditions, dentition, and toxicological investigations were recorded. Then, based on the presence or absence of selected findings and surrounding circumstances, conclusions on the mechanism of death were drawn. ResultsIn eighty-six percent (86%), boluses of meat and sausage or meat-like chunks were observed. Of the forty-nine victims, 22 (42%) had elevated blood alcohol levels (>0.5‰) with blood alcohol concentration (BAC) levels of >0.73‰ to <3.99‰. Of the nonalcoholized decedents, 63% had neurological disorders and 11% had preexisting cardiac conditions. ConclusionsDetecting potential bolus events upon autopsy and the resulting mechanism of nonnatural deaths are of great importance. Therefore, the medical history, resuscitation protocol, and detailed description of the scene of death are essential. Upon autopsy, the type and position as well as size and weight of the bolus and dental status of the victims should be documented in a standardized manner. Additional toxicological investigations are necessary.

Real-World Fingolimod First-Dose Effects in Patients with Pre-Existing Hypertension, Pre-Existing Cardiac Conditions and in Those Receiving Selective Serotonin-Reuptake Inhibitors (P2.065)

Real-World Fingolimod First-Dose Effects in Patients with Pre-Existing Hypertension, Pre-Existing Cardiac Conditions and in Those Receiving Selective Serotonin-Reuptake Inhibitors (P2.065)

Cardiac Exposure in the Dynamic Conformal Arc Therapy, Intensity-Modulated Radiotherapy and Volumetric Modulated Arc Therapy of Lung Cancer.

PurposeTo retrospectively evaluate the cardiac exposure in three cohorts of lung cancer patients treated with dynamic conformal arc therapy (DCAT), intensity-modulated radiotherapy (IMRT), or volumetric modulated arc therapy (VMAT) at our institution in the past seven years.Methods and MaterialsA total of 140 lung cancer patients were included in this institutional review board approved study: 25 treated with DCAT, 70 with IMRT and 45 with VMAT. All plans were generated in a same commercial treatment planning system and have been clinically accepted and delivered. The dose distribution to the heart and the effects of tumor laterality, the irradiated heart volume and the beam-to-heart distance on the cardiac exposure were investigated.ResultsThe mean dose to the heart among all 140 plans was 4.5 Gy. Specifically, the heart received on average 2.3, 5.2 and 4.6 Gy in the DCAT, IMRT and VMAT plans, respectively. The mean heart doses for the left and right lung tumors were 4.1 and 4.8 Gy, respectively. No patients died with evidence of cardiac disease. Three patients (2%) with preexisting cardiac condition developed cardiac disease after treatment. Furthermore, the cardiac exposure was found to increase linearly with the irradiated heart volume while decreasing exponentially with the beam-to-heart distance.ConclusionsCompared to old technologies for lung cancer treatment, modern radiotherapy treatment modalities demonstrated better heart sparing. But the heart dose in lung cancer radiotherapy is still higher than that in the radiotherapy of breast cancer and Hodgkin’s disease where cardiac complications have been extensively studied. With strong correlations of mean heart dose with beam-to-heart distance and irradiated heart volume, cautions should be exercised to avoid long-term cardiac toxicity in the lung cancer patients undergoing radiotherapy.

Use of arsenic trioxide in a hemodialysis-dependent patient with relapsed acute promyelocytic leukemia

Arsenic trioxide has been established for use in both relapsed and front-line treatment of acute promyelocytic leukemia. Dose adjustments are recommended to be considered in severe renal impairment although dosage reduction guidelines are not provided. In addition, toxicities of arsenic are significant. The use of arsenic trioxide has not been well studied in dialysis patients and there is a paucity of data in the literature to support the use in such a situation. We describe an 81-year-old relapsed acute promyelocytic leukemia hemodialysis-dependent patient with a pre-existing cardiac condition who was treated with 10 mg arsenic trioxide three times weekly after dialysis. These findings provide support along with the marginal amount of currently published data for an arsenic trioxide dosing regimen in hemodialysis patients.

G167(P) Chest pain in children is rarely cardiac. does ecg help?

Aims Chest pain is a common reason for presentation to the children’s emergency department (ED). It is known that chest pain in children, compared to adults, is much less likely to be caused by cardiovascular disease. Electrocardiographs (ECGs) are cheap, fast and readily available. When interpreted appropriately they can be useful in demonstrating cardiac causes of chest pain. We aimed firstly to determine the incidence and likely causes of paediatric chest pain presenting to our busy Children’s ED and secondly to analyse the usefulness of ECGs in this cohort. Methods We retrospectively analysed the ED case notes of all children (aged under 16 years) presenting with chest pain over a 4 year period (April 2009 to March 2013) to a busy Children’s ED in an urban district general hospital. Results 1126 attendances presented with chest pain, approximately 1% of all attendances over four years. Of those with chest pain 54% were male and the modal age of presentation was 12 years. Based on history and clinical examination the commonest cause attributed to chest pain was musculoskeletal. Only 1% of cases had a possible cardiac aetiology; 1 patient had pericarditis, 1 patient had myocarditis, 2 patients had a pre-existing cardiac condition, 3 patients had arrhythmias and 8 were under investigation for recurrent palpitations. Thirty per cent of patients with chest pain had an ECG carried out. Patients with cardiovascular, psychiatric and musculoskeletal diagnoses were most likely to have had an ECG done. The majority of ECGs were normal (91%). The commonest abnormality was high take off/mild ST elevation, with only 10% of such patients having cardiac enzymes requested. Some of the ECG abnormalities identified could not be attributed to chest pain. Conclusion Incidence of chest pain presenting to our ED was 1%. The commonest recorded cause was musculoskeletal. Fewer than 1% had a possible cardiac aetiology for chest pain. ECG is a useful test for children presenting with chest pain. Very few patients with mild ST elevation had cardiac enzyme levels checked.

Fingolimod: A Review of Its Use in Relapsing-Remitting Multiple Sclerosis

Fingolimod (Gilenya(®)) is an orally administered disease modifying agent (DMA) for use in relapsing-remitting multiple sclerosis (RRMS). In placebo-controlled trials in patients with RRMS with active disease, fingolimod 0.5 mg/day significantly reduced the annualized relapse rate (ARR) by approximately one-half over 2-year trial periods. It also significantly increased the proportion of patients with no disability progression, reduced deterioration from baseline in the Extended Disability Status Scale score and reduced MRI markers of disease progression (new/newly enlarging brain lesions and percentage change in brain volume). In a 12-month, comparison with intramuscular interferon β-1a (IFNβ- 1a) 30 μg/week, the ARR in fingolimod 0.5 mg/day recipients was significantly lower than in IFNβ-1a recipients by one-half; fingolimod recipients also had significantly lower MRI markers of disease progression. In extensions to the pivotal clinical trials, fingolimod exposure for up to 4 years was associated with low relapse rates and continuing benefits in terms of disability and disease progression. In clinical trials, adverse events in fingolimod recipients were generally mild to moderate in severity. In the pivotal placebo-controlled trial, serious adverse events occurred in similar proportions of fingolimod 0.5 mg/day and placebo recipients. First-dose bradycardia and atrioventricular block, which are generally asymptomatic, were clinically important adverse events associated with fingolimod in placebo-controlled trials. The risk for serious cardiovascular adverse events at the approved fingolimod dosage appears to be low in patients without pre-existing cardiac conditions. Fingolimod is an efficacious therapy for RRMS that reduces relapses, disability progression, new brain lesions and loss of brain volume. It has an acceptable tolerability profile and provides a useful alternative treatment in patients with RRMS who have responded poorly to other DMAs.

First-dose effects of fingolimod after switching from injectable therapies in the randomized, open-label, multicenter, Evaluate Patient OutComes (EPOC) study in relapsing multiple sclerosis

BackgroundIn pivotal phase 3 studies, fingolimod treatment initiation was associated with a transient reduction in heart rate (HR). Atrioventricular (AV) conduction delays, which were typically asymptomatic, were detected in a small minority of patients. ObjectiveWe report the first-dose effects of fingolimod in patients who switched from injectable therapies during the Evaluate Patient OutComes (EPOC) study (ClinicalTrials.gov Identifier: NCT01216072). MethodsThis was a phase 4, 6-month, randomized, active-comparator, open-label, multicenter study. It included over 900 fingolimod-treated patients with relapsing multiple sclerosis, with subgroups of individuals who were receiving common concomitant HR-lowering medications or had pre-existing cardiac conditions (PCCs). Vital signs were recorded hourly for 6h post-dose. A 12-lead electrocardiogram was obtained at baseline and at 6h post-dose. ResultsA transient decrease in mean HR and blood pressure occurred within 6h of the first fingolimod dose. The incidence of symptomatic bradycardia was low (1%); eight patients reported dizziness and there was one case each of fatigue, palpitations, dyspnea, cardiac discomfort, and gait disturbance. These symptomatic events were typically mild or moderate in severity and all resolved spontaneously, without intervention or fingolimod discontinuation. ConclusionFirst-dose effects in patients with PCCs and in those receiving concomitant HR-lowering medications were consistent with effects observed in the overall study population and with results from previous clinical trials. The EPOC study provides additional data demonstrating the transient and generally benign nature of fingolimod first-dose effects on HR and AV conduction in a large population that is more representative of patients encountered in routine clinical practice than in the pivotal trials.

Preprocedure prophylaxis against endocarditis among United States pediatric cardiologists.

This study aimed to determine current practices regarding prophylaxis against infective endocarditis among pediatric cardiologists in the United States 5 years after publication of the most recent American Heart Association (AHA) recommendations. A descriptive, analytical, cross-sectional study was conducted from June 2012 to November 2012 in the format of an anonymous self-administered e-mailed questionnaire among pediatric cardiologists across the United States. The questionnaire inquired about demographic information of cardiologists and their current practices of prescribing preprocedure antibiotic prophylaxis against endocarditis to patients with specific preexisting cardiac conditions. Descriptive analyses were done in percentages. Frequency and exploratory statistical analyses were done by the Chi-square method. Of the 980 cardiologists invited, 221 (23 %) responded to the survey. The findings showed that pediatric cardiologists generally follow the AHA guidelines. The most common cardiac conditions in which antibiotics were administered despite AHA guidelines not requiring prophylaxis were rheumatic heart disease with aortic insufficiency, transposition of the great vessels after the Mustard procedure, bicuspid aortic valve with severe aortic stenosis, cardiac transplantation without valvar disease, and bicuspid aortic valve with severe aortic insufficiency. More experienced pediatric cardiologists were significantly more likely to administer prophylaxis to certain patients than their less experienced peers. Many pediatric cardiologists in the United States continue to administer preprocedure antibiotic prophylaxis against endocarditis even when not recommended to do so per the 2007 AHA guidelines. With certain lesions, highly experienced pediatric cardiologists are more likely to administer prophylaxis than their less experienced counterparts.

Adverse events following immunization in Ontario's female school-based HPV program

BackgroundIn September 2007, a school-based human papillomavirus (HPV) vaccination program targeting grade 8 girls (approximately 13 years old) and delivered by public health was implemented in Ontario, Canada. We assessed reports of adverse events following immunization (AEFI) from the school-based program as part of quadrivalent HPV (HPV4) vaccine safety surveillance and to contribute to a comprehensive HPV vaccine program evaluation. MethodsAEFIs following HPV4 vaccine (Gardasil®) administered between September 1, 2007 and December 31, 2011 were extracted from the province's reportable disease system. Confirmed AEFI reports among females 12–15 years old (i.e. assumed to have received vaccine through the program) were included. Events were grouped according to provincial AEFI case definitions. Rates were calculated using doses distributed as the denominator. ResultsBetween 2007 and 2011, 133 confirmed AEFIs were reported while 691,994 HPV4 vaccine doses were distributed in the school-based program. The overall reporting rate was 19.2 HPV4 AEFI per 100,000 doses distributed. Annual reporting rates decreased from 30.0 to 18.3 per 100,000 doses distributed. Frequently reported events included ‘allergic reaction—dermatologic/mucosa’ (25%), ‘rash’ (22%), and ‘local/injection site reaction’ (20%); 26% of reports had a non-specific event of ‘other severe/unusual events’ selected. Ten serious AEFIs were reported (7.5% of reports) including 2 anaphylaxis, 2 seizures, 1 thrombocytopenia and 1 death. Further review found that the reports of anaphylaxis did not meet the Brighton anaphylaxis definition and the death was attributed to a preexisting cardiac condition. ConclusionsOverall these findings are consistent with the safety profile of HPV4 vaccine from pre-licensure clinical trials and post-marketing surveillance reports and importantly, no new safety signals were identified, especially no reports of VTE in this younger female population. Continued assessment of HPV4 AEFI surveillance data may be important to detect and investigate safety signals.

FDA Responds toAJPManuscript on Citalopram Safety

FDA Responds to<i>AJP</i>Manuscript on Citalopram Safety

Maternal cardiac arrest in a tertiary care centre during 1989-2011: a case series

To review and report maternal and neonatal outcomes after cardiac arrest during pregnancy in a large tertiary care centre and to consider steps to improve the outcomes. We performed a retrospective chart review of maternal cardiac arrest in the Mount Sinai Hospital, University of Toronto health records database for the period 1989-2011. Five cases were identified for an incidence of 1:24,883 deliveries (0.004%). Four of the five women were obese and older than 35 yr. Two women had pre-existing cardiac conditions, and one had placenta accrete. All three underwent perimortem Cesarean delivery (PMCD), but none of these procedures was done within the recommended time of the "four-minute rule." Two of the three women had repeated arrests and subsequently died. The other two women were in labour, received regional analgesia, and had assisted vaginal deliveries. Both of these patients survived, and all survivors (mothers and neonates) were neurologically intact. Four of five neonates survived. The etiology of the cardiac arrest was indeterminate in all five cases, although suspected amniotic fluid embolism was considered the most likely contributing factor in the majority of cases. Overall, the quality of the charting was inconsistent and incomplete. This series of five cases highlights the challenges to meeting the rule of initiating PMCD within four minutes of maternal cardiac arrest onset. We suggest focusing on the quality of ongoing resuscitation efforts and early delivery as our experience shows that mother and neonate can survive beyond five minutes after arrest. Improved documentation and creation of a national database for these rare events should be considered.

Influenza A induced cellular signal transduction pathways.

Influenza A is a negative sense single stranded RNA virus that belongs to the Orthomyxoviridae Family. This enveloped virus contains 8 segments of viral RNA which encodes 11 viral proteins. Influenza A infects humans and is the causative agent of the flu. Annually it infects approximately 5% to 15% of the population world wide and results in an estimated 250,000 to 500,000 deaths a year. The nature of influenza A replication results in a high mutation rate which results in the need for seasonal vaccinations. In addition the zoonotic nature of the influenza virus allows for recombination of viral segments from different strains creating new variants that have not been encountered before. This type of mutation is the method by which pandemic strains of the flu arises. Infection with influenza results in a respiratory illness that for most individuals is self limiting. However in susceptible populations which include individuals with pre-existing pulmonary or cardiac conditions, the very young and the elderly fatal complications may arise. The most serious of these is the development of viral pneumonia which may be accompanied by secondary bacterial infections. Progression of pneumonia leads to the development of acute respiratory distress syndrome (ARDS), acute lung injury (ALI) and potentially respiratory failure. This progression is a combined effect of the host immune system response to influenza infection and the viral infection itself. This review will focus on molecular aspects of viral replication in alveolar cells and their response to infection. The response of select innate immune cells and their contribution to viral clearance and lung epithelial damage will also be discussed. Molecular aspects of antiviral response in the cells in particular the protein kinase RNA dependent response, and the oligoadenylate synthetase RNAse L system in relation to influenza infection.

High-sensitivity troponin T is predictive of adverse outcome after acute ischemic stroke

Purpose: High-sensitivity cardiac troponin T (hs-cTnT) is used for risk stratification in cardiac diseases. Data on cTnTs and ischemic stroke are conflicting due to low analytical sensitivity. We investigated hs-cTnT as a predictor for stroke outcome. Methods: 517 consecutive stroke patients screened. Data included onset time, severity scales on admission and discharge[NIH Stroke Scale (NIHSS), modified Rankin Scale (mRS), Barthel Index (BI)], and various clinical/laboratory parameters. At day 90, mRS and BI were assessed by telephone interview. Exclusions: transient ischemic attacks, bleedings, undetermined onset, no hs-cTnT<24 h, estimated glomerular filtration rate (eGFR)<15 ml/min, MI during stay or 4 weeks prior, no follow-up. Final sample: 340 patients. Definitions for adverse outcome: death; mRS>2; BI 3 and/or BI<60 combined. hs-cTnT was divided into 5 groups: <5 ng/L; quartiles of elevated hs-cTnT (Q1 5.09-8.0; Q2 8.29-12.6; Q3 12.76-27.62, Q4 27.7-221 ng/L). hs-cTnT vs. outcomes and other parameters, and odds ratios (ORs) for outcomes vs. hs-cTnT were calculated using multivariate logistic regression. P for trend was calculated from group medians. Results: Median age, 68 years (range 18-96); 208 men. 117 (52%) had hs-cTnT levels<5ng/L. Median hs-cTnT (Q1 to Q4): 6.70, 10.30, 18.65, and 43.0 ng/L. Patients with higher hs-cTnT were older, more often male, and more severely ill. There was a significant rise of NIHSS and adverse outcomes over quartiles. eGFR, Hb, and CRP were more pathological in higher quartiles. Stroke etiology was more likely cardiac, and heart conditions (atrial fibrillation, coronary heart disease) more prevalent in Q3/Q4. Associations between hs-cTnT and outcomes remained significant after adjustment for heart conditions. hs-cTnT was independently associated with all adverse outcomes (p for trend<0.001). NIHSS and age were the only other independent predictors. Conclusions: hs-cTnT is independently predictive of adverse stroke outcomes after 90 days. Associations with definitions of outcome were robust. Categorization of hs-cTnT into quartiles showed a dose-effect relation, with significantly higher ORs in the more elevated groups. Multivariate adjustment for preexisting cardiac conditions did not alter significance. Hence, hs-cTnT elevation may indicate cerebral impairment translating into cardiac damage rather than vice versa. Stress-induced patchy myocytolysis caused by centrally mediated vegetative fluctuations has been implicated. hs-cTnT is a functionally meaningful predictor of clinical course; pathophysiological connections, however, still need to be elucidated.

What Keeps Patients with Subarachnoid Hemorrhage in the Neurosciences ICU?

Anticipated neurological intensive care unit length of stay is of interest to intensivists, administrators, patient families, neurologists, and neurosurgeons alike. Although some may equate length of stay with outcome, a measure more commonly addressed in the literature, these are two distinct entities. Patients with poor outcomes may have very brief lengths of stay as a result of early redirection of care, and thus, the issue of length of stay encompasses patients that, despite successful and aggressive care, may continue to serve as an ongoing challenge to intensivists. Intuitive neurological factors that prolong length of stay after aneurysmal subarachnoid hemorrhage include the vasospasm period and hydrocephalus. The severity of the former is influenced by patient age [1, 2], presenting clinical grade [3, 4], amount of subarachnoid blood [3, 4], and, as has been elegantly demonstrated by another recent post hoc analysis of CONSCIOUS-1, treatment modality [5]. However, the duration of the vasospasm period is not only influenced by these factors; it may also be influenced by varying vasospasm protocols as more aggressive approaches such as balloon angioplasty may shorten the period. At the conclusion of the vasospasm period, weaning of a ventriculostomy and/or placement of a shunt may be another factor prolonging ICU stay. Aside from neurological factors, medical conditions that arise as a result of subarachnoid hemorrhage such as severe myocardial stunning or neurogenic pulmonary edema may also prolong ICU stay. Of course, medical co morbidities in themselves particularly pre-existing cardiac conditions which may be stressed by the vasospasm period or respiratory conditions that may be stressed by altered mental status, pulmonary edema, pneumonia, and aggressive hydration may also prolong ICU stay. Of course, a long ICU stay in itself can ‘‘lengthen’’ ICU stay as a result of thromboembolic or infectious complications. However, many of these medical factors arise as time in the ICU passes and thus, to better counsel patient families and plan for aggressive care, early predictors of prolonged ICU stay are important to identify. Witiw and colleagues from the University of Toronto have performed an interesting post hoc analysis of patients in CONSCIOUS-1 [6] to elucidate factors on admission associated with prolonged length of stay after aneurysmal SAH. They found that age, clinical grade, pre-existing hypertension, intraparenchymal hemorrhage, and intraventricular hemorrhage were associated with prolonged critical care stays. Although increasing age may be protective from the perspective of vasospasm, it is intuitively deleterious from the perspective of arising medical co morbidities prolonging ICU stay and has sensibly arisen as a factor prolonging ICU stay. Clinical grade at presentation is a surrogate for hydrocephalus and is known to correlate with vasospasm [3, 4]—it is thus not at all surprising that this correlated with ICU length of stay as has been demonstrated in another smaller study [7]. As the authors only evaluated hypertension and hyperglycemia as potential presenting medical co morbidities, it is not surprising that associated-hypertension was significant, as this is likely a surrogate for other medical co morbidities that were not specifically evaluated. Intraventricular hemorrhage arising as a significant factor prolonging ICU stay is also sensible from the perspective of a greater proclivity toward ventriculostomy/shunt dependence. Interestingly, although ‘‘hydrocephalus’’ itself did not impact ICU stay in this B. A. Gross (&) Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA e-mail: bgross1@partners.org

Diesel Exhaust Inhalation Increases Cardiac Output, Bradyarrhythmias, and Parasympathetic Tone in Aged Heart Failure–Prone Rats

Acute air pollutant inhalation is linked to adverse cardiac events and death, and hospitalizations for heart failure. Diesel engine exhaust (DE) is a major air pollutant suspected to exacerbate preexisting cardiac conditions, in part, through autonomic and electrophysiologic disturbance of normal cardiac function. To explore this putative mechanism, we examined cardiophysiologic responses to DE inhalation in a model of aged heart failure-prone rats without signs or symptoms of overt heart failure. We hypothesized that acute DE exposure would alter heart rhythm, cardiac electrophysiology, and ventricular performance and dimensions consistent with autonomic imbalance while increasing biochemical markers of toxicity. Spontaneously hypertensive heart failure rats (16 months) were exposed once to whole DE (4h, target PM(2.5) concentration: 500 µg/m(3)) or filtered air. DE increased multiple heart rate variability (HRV) parameters during exposure. In the 4h after exposure, DE increased cardiac output, left ventricular volume (end diastolic and systolic), stroke volume, HRV, and atrioventricular block arrhythmias while increasing electrocardiographic measures of ventricular repolarization (i.e., ST and T amplitudes, ST area, T-peak to T-end duration). DE did not affect heart rate relative to air. Changes in HRV positively correlated with postexposure changes in bradyarrhythmia frequency, repolarization, and echocardiographic parameters. At 24h postexposure, DE-exposed rats had increased serum C-reactive protein and pulmonary eosinophils. This study demonstrates that cardiac effects of DE inhalation are likely to occur through changes in autonomic balance associated with modulation of cardiac electrophysiology and mechanical function and may offer insights into the adverse health effects of traffic-related air pollutants.

Preparticipation screening and prevention of sudden cardiac death in athletes: Implications for primary care

The purposes of this article are to explore the mechanism of sudden cardiac death (SCD) in young athletes and examine how preparticipation screenings help identify precipitating cardiac abnormalities. Electrocardiogram (ECG) testing has been implicated to play an important role in detecting subtle abnormalities that may cause SCD, but the routine implementation of this diagnostic tool remains a debate among experts. This report was compiled by reviewing the scientific literature on SCD in athletes, preparticipation exams, and current screening guidelines using CINAHL, MEDLINE, and PubMed search engines. Although the American Heart Association guidelines do not include ECG testing for preparticipation screenings, the implementation of routine ECG testing for preparticipation sports physicals is effective in preventing SCD in athletes. Primary care providers should be aware of current guidelines for screening patients for heart diseases that predispose them to SCD and their legal obligations to be sure these athletes are safe. The implementation of ECG testing will assist in the decision whether to disqualify an athlete from participation as a result of preexisting cardiac conditions, and ultimately preventing the untimely death of a young athlete.

Comparison between 155 cases of robotic vs. 150 cases of open surgical staging for endometrial cancer

ObjectiveTo compare the outcomes of 155 cases of endometrial cancer who had robot-assisted surgical staging to 150 open cases. MethodsRetrospective chart review of cases of endometrial cancer that underwent staging two different ways by two surgeons at an academic institution. ResultsMean age was 62.4years in the robotic arm and 65 (P=0.04) in the open arm. Mean body mass index was 34.5Kg/m2 in the robotic arm and 33Kg/m2 in the open arm (P=0.2). Pelvic and para-aortic lymph node dissection were performed in 94.8% and 67.7% of the robotic cases versus 95.3% and 74% of the open cases, respectively. Mean operative time was 127min in the robotic arm, and 141min in the open arm (P=0.0001). Mean lymph node count was 20.3 in the robotic arm, and 20 in the open arm (P=0.567). Mean estimated blood loss was 119ml in the robotic arm and 185 in the open arm (P=0.015). Mean hospital stay was 1.5days in the robotic arm, and 4days in the open arm (P=0.0001). The incidence of postoperative ileus (0.6% vs. 10.7%, P=0.0001), infections (5.2% vs. 24%, P=0.0001), anemia/transfusion (1.3% vs. 7.7%, P=0.005), and cardiopulmonary complications (3.2% vs.14.7%, P=0.003) was significantly lower in the robotic arm vs. the open arm. There was one death in the robotic arm attributed to pre-existing cardiac condition. ConclusionRobotic-assisted staging reaps the benefits of minimally invasive surgery without compromising the adequacy of the procedure. Dedication to the technique shortens the operative time.

Bortezomib-Induced Congestive Cardiac Failure in a Patient with Multiple Myeloma

Bortezomib therapy is known to be associated with neurological side effects and thrombocytopenia. Its cardiac side effects are however not well known. The patient, a 70-year-old woman, with a previous history of myocardial infarction and subsequent coronary stenting, was detected to have multiple myeloma stage IIIa. She was started on Inj. Bortezomib (1.3mg/m(2)) and Tab. Dexamethasone 40mg on a weekly basis. She showed good response to therapy. Three days after administration of the 22nd dose of bortezomib, she presented to the hospital with congestive cardiac failure. Echocardiography revealed a drop in the left ventricular ejection fraction from pretreatment levels of 45-50 to 25%. Patient was treated medically for left ventricular failure secondary to a suspected ischemic etiology. Coronary angiography revealed non-critical coronary artery disease with patent right coronary artery and left circumflex stents. The N-terminal pro-brain natriuretic peptide (NT-proBNP) levels that were initially raised 4,030pg/ml (<125pg/ml) declined to 2,280pg/ml a week later and subsequently normalized over the next 2weeks. The patient responded well to treatment and was then discharged. The left ventricular ejection normalized over the next 3months. Cardiac side effects of bortezomib are not well reported. Elderly patients and those with preexisting cardiac conditions could be at increased cardiovascular risk. Since this risk increases once a cumulative dose of 20mg/m(2) has been administered, patients need to be monitored more intensively once this threshold has been attained. Increased awareness of these cardiac side effects is necessary for patients' safety.

Spectrum of cardiovascular findings during pregnancy and parturition at a tertiary referral center

To analyze the spectrum of cardiovascular diseases occurring during pregnancy and delivery at a tertiary referral center. All patients presenting at our institution with pre-existing or first diagnosis of cardiac disease were recruited. Cardiac and obstetric complications and maternal and neonatal outcomes were recorded. Fifty-two pregnancies in 49 women, including three pregnancy terminations were analyzed. Cardiac lesions were congenital in 26 (53.1%) and acquired in nine (18.4%); six patients (12.2%) had cardiomyopathies, eight (16.3%) ar-rhythmic conditions. A total of 42 women (85.7%) had a pre-existing cardiac condition and seven (14.3%) presented with first manifestation. Overall 22 cardiac complications occurred: five in pregnancy, eight around parturition, nine during follow-up. They included >1 New York Heart Association functional class deterioration (n=5), congestive heart failure/cardiomyopathy (n=5), valve replacement (n=4), sustained arrhythmia (n=3), cerebral insult, aortic dissection, transplantation (one case each), and death (n=2). Mean gestational age at delivery was 36+6. The cesarean section rate was 77.5%; 31.6% were performed for cardiac indications. Obstetric complications happened in 23 pregnancies (46.9%). There was no perinatal loss; cardiac defects were diagnosed in 9.3% (n=5) of offspring. Cardiovascular diseases occurring during pregnancy and parturition comprise a heterogeneous spectrum of conditions. Established scores aid in the identification of high-risk patients; however, in our series 14.3% women had been healthy previously.