Signs Of Left Ventricular Failure Research Articles

Neurogenic Pulmonary Edema: A Case Report

Background: Neurogenic pulmonary edema (NPE) is a rare pulmonary edema that develops rapidly after an acute central nervous system injury. The mechanism by which neurological insult leads to pulmonary edema is not well understood. The clinical presentation of NPE varies widely and ranges from asymptomatic cases to fulminant cases. Clinical signs in pure NPE are usually those of acute pulmonary edema, without signs of left ventricular failure. Case Report: The author presents a case of NPE is a young female patient with a brief epileptic seizure in which NPE resolved within 48 hours. Patient had no respiratory symptoms but was initially placed on antibiotics because her chest x-ray showed bilateral lung patchy opacifications in a perihilar distribution suggestive of pulmonary edema and/or multifocal pneumonia. Antibiotics was discontinued when the pulmonary edema resolved. Conclusion: There is need for physicians to be aware of NPE to avoid unnecessary antibiotics in asymptomatic patients who present with bilateral pulmonary infiltrates following an epileptic seizure.

SAT-LB307 Case of the Broken Hearted

Phaeochromocytomas are rare neuroendocrine tumours which, usually present with headache, diaphoresis, episodic tachycardia and hypertension. Takotsubo-pattern cardiomyopathy is an unusual initial presentation of phaeochromocytomas, however has been reported1. Approximately 10% of phaeochromocytomas present with cardiomyopathy. It is associated with a high mortality risk and early intervention with surgery is the key to recovery. We report a case of a previously healthy, 68 year old man who presented with symptoms of left ventricular failure, and feeling anxious. Physical examination revealed signs of left ventricular failure, with a normal blood pressure and heart rate. A transthoracic echocardiogram (TTE) revealed dilated left ventricle with severe global hypokinesis and a left ventricular ejection fraction (LVEF) of 15%. A CTPA performed to exclude pulmonary embolism revealed an incidental right sided adrenal lesion measuring 3.9 X 3.4 X 3.7 cm. Subsequently a dedicated abdominal CT confirmed the adrenal lesion. Biochemistry revealed elevated 24 hour urine catecholamines and metanephrines and an elevated plasma metanephrines. Subsequently he proceeded to have adrenalectomy. Pre-operatively the patient was managed with alpha and beta blocking agents for 3 weeks prior to surgery. Post-operative course was uneventful and histopathology confirmed right sided phaeochromocytoma. TTE performed 12 months post-operatively showed a significant improvement in his LVEF to 40 % with subsequent TTE showing maintenance of LVEF. This case demonstrates highlights the unusual presentations of phaeochromocytomas and that early recognition and early intervention with surgery is the key to recovery to avoid catastrophic cardiac events.1. Chiang YL, Chen PC, Lee CC, et al. Adrenal pheochromocytoma presenting with Takotsubo-pattern cardiomyopathy and acute heart failure: A case report and literature review. Medicine (Baltimore)2016;95(36):e4846. doi: 10.1097/MD.0000000000004846 [published Online First: 2016/09/08]

Clinical Presentation, Risk Factor, and Outcomes of Acute Coronary Syndrome in Women at an Urban Referral Center in Dakar, Senegal

BackgroundCardiovascular disease is on the rise in Sub-Saharan countries. Recently, consistent studies have reported sex differences in the epidemiology of acute coronary syndrome (ACS). Although, data on the incidence of ACS in Sub-Saharan countries are not rare, few focused closely on women. ObjectivesThe purpose of this study was to examine risk factors, clinical presentations, and management strategies in women with ACS. MethodsThis was a retrospective study conducted at the Cardiology Department of Principal Hospital of Dakar over a period of 60 months (January 1, 2010, to December 31, 2014), in Dakar, Senegal. Medical records of female subjects admitted for ACS on the basis of anginal pain at rest, suggestive electrocardiographic changes, and elevated troponin I levels were included. We collected and analyzed the epidemiological, clinical, paraclinical, and evolutionary data of the patients. ResultsHospital prevalence of ACS in women was 2.32%, meaning 38.1% of patients were admitted for ACS during the same period. The mean age of patients was 68.8 ± 9.5 years; 52% of them were aged between 60 and 69 years. The risk factors in our patients were dominated by hypertension found (63.3%) and diabetes (54.1%). Active smoking was found in 6 patients (6.1%). One-half of patients had more than 1 risk factor. Chest pain was present in 94 patients (95.9%).The average time delay before medical care was administered was 53.9 ± 18 h. Thirty patients showed signs of left ventricular failure (Killip classes I and II). Electrocardiography revealed ACS with persistent ST-segment elevation in 53 patients (54.1%) and non–ST-segment elevation ACS in 45 patients (45.9%). Mean troponin I level was 1.68 ± 2.3 ng/ml. Doppler echocardiography revealed impaired segmental kinetics in more than one-half of patients. The mean ventricular ejection fraction was 43.8 ± 10.1%. Thrombolysis was performed in 10 patients, accounting for 10.2% of patients with ST-segment elevation. The evolution during hospitalization after a mean hospital stay of 9.5 ± 3.7 days was favorable in 66 patients (67.3%). Six deaths (6.1%) were recorded. Complications was dominated by pulmonary edema. ConclusionsOur study confirms that ACS is not a “man's only” disease in Sub-Saharan countries. The major concern is that there appeared to be continuing evidence of suboptimal treatment and intervention in women with ACS in current practice.

Dilated Cardiopathy Associated with Sickle Cell Disease in a 68 Years Old Female: An Emerging Complication in Sub-sahara Africa

Sickle Cell Anemia (SCA) is an autosomal recessive disease caused by a point mutation in the hemoglobin beta gene found on chromosome 11p15.5 [1]. Specifically, it occurs when a single base from A to T in the codon for glutamic acid at position 6 is changed to valine of the beta globin and thus disrupts the tertiary structure and stability of the hemoglobin molecule [2]. Sickle hemoglobin is responsible for wide spectrum of disorders which vary with respect to severity of anemia, frequency of crises and duration of survival [3]. We present the case of a dilated cardiopathy in an elderly female sickle cell patient. A 68 years old female sickle cell patient with no known major cardiovascular risk factor presented with progressive onset of dyspnea. Clinical examination showed signs of left ventricular failure; an electrocardiogram showed a sinus regular rhythm, left ventricular hypertrophy with systolic overload, Q waves in the anteroseptal leads. Cardiac ultrasound showed a dilated cardiopathy with a preserved left ventricular systolic function at 57%, normal regional wall motion and normal pulmonary pressure. We concluded of heart failure due to probable chronic anemia or anischemic cardiopathy with a conserved systolic function in an elderly sickle cell patient but we were not able to confirm the main etiology without CT Coronary Angiogram or coronarography. Sickle cell anemia is a common genetic condition in sub-Saharan Africa associated with early death. This case is special because we have an elderly female presenting with heart failure on a dilated cardiopathy. This enhances the necessity of strict cardiovascular follow up of Sickle cell patient.

MS02.7 Nationwide Assessment of Hypertension Among the Adult Population In Bangladesh

Cardiovascular disease is on the rise in Sub-Saharan countries. Recently, consistent studies have reported sex differences in the epidemiology of acute coronary syndrome (ACS). Although, data on the incidence of ACS in Sub-Saharan countries are not rare, few focused closely on women.The purpose of this study was to examine risk factors, clinical presentations, and management strategies in women with ACS.This was a retrospective study conducted at the Cardiology Department of Principal Hospital of Dakar over a period of 60 months (January 1, 2010, to December 31, 2014), in Dakar, Senegal. Medical records of female subjects admitted for ACS on the basis of anginal pain at rest, suggestive electrocardiographic changes, and elevated troponin I levels were included. We collected and analyzed the epidemiological, clinical, paraclinical, and evolutionary data of the patients.Hospital prevalence of ACS in women was 2.32%, meaning 38.1% of patients were admitted for ACS during the same period. The mean age of patients was 68.8 ± 9.5 years; 52% of them were aged between 60 and 69 years. The risk factors in our patients were dominated by hypertension found (63.3%) and diabetes (54.1%). Active smoking was found in 6 patients (6.1%). One-half of patients had more than 1 risk factor. Chest pain was present in 94 patients (95.9%).The average time delay before medical care was administered was 53.9 ± 18 h. Thirty patients showed signs of left ventricular failure (Killip classes I and II). Electrocardiography revealed ACS with persistent ST-segment elevation in 53 patients (54.1%) and non–ST-segment elevation ACS in 45 patients (45.9%). Mean troponin I level was 1.68 ± 2.3 ng/ml. Doppler echocardiography revealed impaired segmental kinetics in more than one-half of patients. The mean ventricular ejection fraction was 43.8 ± 10.1%. Thrombolysis was performed in 10 patients, accounting for 10.2% of patients with ST-segment elevation. The evolution during hospitalization after a mean hospital stay of 9.5 ± 3.7 days was favorable in 66 patients (67.3%). Six deaths (6.1%) were recorded. Complications was dominated by pulmonary edema.Our study confirms that ACS is not a “man's only” disease in Sub-Saharan countries. The major concern is that there appeared to be continuing evidence of suboptimal treatment and intervention in women with ACS in current practice.

Option for the Radial versus Femoral Access in Coronary Intervention in Acute Coronary Syndromes: A Risk-Treatment Paradox

Abstract Background: In coronary procedures, although the radial approach protects patients from hemorrhagic complications, it is technically more complex than the femoral approach. Objectives: To test the hypothesis that the radial approach is the procedure of choice in ACS patients due to the high risk of bleeding; and to identify independent predictors of the choice for radial access. Methods: Patients admitted for ACS who underwent invasive coronary procedure were included. We registered the type of access (femoral or radial) chosen by the physician for the first angiography; the investigators did not interfere with this choosing process. Student’s t-test was used for comparisons between the CRUSADE and ACUITY scores. Predictors of radial access were compared between the groups. Statistical significance was defined by p < 0,05. Results: Radial access was chosen in 67% of 347 consecutive patients. Patients who underwent radial approach had lower risk of bleeding determined by CRUSADE (30 ± 14 vs. 37 ± 15; p < 0.001) as compared with femoral access. In multivariate analysis, four variables were identified as independent predictors negatively associated with radial access - age (OR = 0.98; 95%CI = 0.96 - 0.99), creatinine (OR = 0.54; 95%CI = 0.3 - 0.98), signs of left ventricular failure (OR = 0.45; 95% CI = 0.22 - 0.92) and previous CABG (OR = 0.022; 95%CI = 0.003 - 0.166). Conclusion: The propensity to choose radial over femoral access in coronary intervention was not primarily influenced by patients’ bleeding risk. Predictors of this decision, identified in the study, indicated less complex patients, suggesting that the difficulty in performing the technique was a stronger determinant than its potential antihemorrhagic effect. (Int J Cardiovasc Sci. 2018; [online].ahead print, PP.0-0)

Postoperative Acute Lung Injury Following Lobectomy for Non-Small Cell Lung Cancer: What Are the Risk Factors?

SESSION TITLE: Lung Cancer SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Acute lung injury following lung resection surgery is not rare and is often related to mortality. Although there is a significant clinical and economic impact associated with increased intensive care unit (ICU) utilization, length of hospital stay, and associated cost, these factors cannot be predicted with any accuracy. The aim of this study was to identify the modifiable risk factors of postoperative acute lung injury (PALI) following lung cancer surgery. METHODS: We retrospectively analyzed the medical records of 354 cases of lung cancer surgery from a tertiary university hospital spanning the period from January 2012 to December 2015. PALI was defined, within one week postoperatively, as bilateral diffuse pulmonary infiltration on chest radiography, oxygenation failure (PaO2/FiO2 < 300), and the absence of signs of left ventricular failure. We classified patients into one of two groups, PALI or non-PALI, and compared the clinical characteristics between the two groups. A logistic regression model was fitted to evaluate the risk factors of PALI. RESULTS: Among 354 cases of lung cancer surgery, 287 lobectomies were analyzed. The overall incidence of PALI was 2.79% (8/287); four patients developed pneumonia with acute respiratory distress syndrome, and four patients developed ALI with no clinical signs of infection. There was no difference in baseline characteristics between the PALI and non-PALI groups; however, regarding surgical parameters, a higher volume of fluid infusion was observed in the PALI group. The logistic regression model revealed underlying ischemic heart disease (odds ratio (OR) 7.67, 95% confidence interval (CI) 1.21-47.44, p=0.03), interstitial lung disease (OR 30.36, 95% CI 2.30-401.52, p=0.01), intraoperative intravascular crystalloid fluid (OR 1.10, 95% CI 1.00-1.20, p=0.04), and intraoperative transfusion (OR 56.4, 95% CI 3.53-901.39, p<0.01) as risk factors of PALI. PALI increased the frequency of ICU admission, the use of mechanical ventilation, the duration of hospital stay, and mortality. CONCLUSIONS: The clinical impacts of PALI are considerable. The significant independent risk factors identified were underlying ischemic heart disease, interstitial lung disease, intravascular crystalloid fluid, and intraoperative transfusion. CLINICAL IMPLICATIONS: Close observation is necessary for patients with ischemic heart disease or interstitial lung disease, following lung cancer surgery, to identify the development of acute lung injury can be avoided and optimize the intraoperative fluid and transfusion. DISCLOSURE: The following authors have nothing to disclose: Hyun Jung Kim, Chan-Hee Lee No Product/Research Disclosure Information

Cardiovascular magnetic resonance, mitral regurgitation and outcomes: the importance of accurate assessment in an era of increasing intervention.

Assessing the severity of mitral regurgitation has been part of clinical practice since the advent of the stethoscope (presence of S3, soft S1, early A2, signs of pulmonary hypertension—loud P2 and parasternal heave, displaced apex beat, signs of left ventricular failure). Nowadays, imaging with echocardiography is the worldwide standard with its ability to give semi-quantitative and quantitative measures, including vena contracta length, effective regurgitant orifice area (EROA) and regurgitant volume (RVol) using the proximal isovelocity surface area (PISA) method, and measures of the haemodynamic consequences of mitral regurgitation (pulmonary vein systolic flow reversal, LV end-systolic diameter, left atrial area or volume, pulmonary systolic arterial pressure at rest).

Positive end-expiratory pressure adjustment in parenchimal respiratory failure: static pressure-volume loop or transpulmonary pressure?

The aim of the study was compare the prognostic value, efficacy and safety ofpositive end-expiratory pressure (PEEP) adjustment in conformity with lower inflection point of static "pressure-volume" loop (LIP) or end-expiratory esophageal pressure (EEEP) in parenchymal respiratory failure. We included in the study 56 patients (39 males) at age 47 +/- 17.8 years with parenchymal respiratory failure (PaO2/FiO2 < 250 mmHg, bilateral infiltrates on chest X-ray or lung CT scan, no signs of left ventricular failure), who were mecAanically ventilated for less than 48 hours. All patients were sedated and paralyzed. We measured intra- Sabdominal pressure, PaO2/FiO2, PaCO2, alveolar dead space (Vdalv), plotted static "pressure-volume" loop by low flow technique in range of 0 to 40 mbar, recording LIP Then we placed nasogastric tube with balloon for esophageal pressure measurement and measured esophageal pressure at PEEP range from 8 to 20 mbar (with 2 mbar steps) and recorded plateau pressure (Pplat), transpulmonary plateau pressure (Ptp plat), transpulmonary pressure at PEEP level (Ptp PEEP), static compliance of respiratory system (Cstat), lung compliance (Clung), chest wall compliance (Ccw) at every step. Also by volumetric capnography technique we measured end-tidal carbon dioxide concentration (EtCO2), minute volume of exhaled carbon dioxide (VCO2) volume of exhaled carbon dioxide by single breath (VtCO2) and calculate VC2/EtCO2 as a surrogate marker of pulmnonary perfusion. After that we set PEEP at EEEP level (at zero end-expirato- my ranspulmonary pressure) and recorded changes of PaO2/FiO2 and Vdalv. LIP value was 5 (6-10) mbar and it was less than empirically set PEEP in most of patients before enrollment and had no prognostic value for PEEP setting. EEEP level was 14 (12-18.25) mbar and it was higher than LIP in 96.4% patients. Distribution of EEEP values was close to normal unlike LIP Chest wall compliance was less than normal (100 ml/mbar) in 46% of patients. EEEP has correlation with body mass index (rho 0.554, p=0.002). We did not find any correlation between intra-abdominal pres- sure (IAP) and EEEP (p=0.376) or IAP and LIP (p=0.464). PEEP levels higher than 14 mbar led to significant decrease in Cstat and Clung (p<0.001). We observed significant decrease in VCO at PEEP levels more than 16 mbar, i.e., more than EEEP median. PEEP levels more than 16 mbar decreased VCO2/EtCO2, (decreased pulmonary perfusion) from 7.47 (6.54-8.7) at PEEP 14 mbar to 7.32 (6.35-8.76) at PEEP 20 mbar (p=0.004). PEEP setting at EEEP level increased PaO/FiO2 from 205 (154-235) to 280 (208-358) mmHg (p<0.001), did hot change Vdalv (p=0.093) and decreased Cstat and Clung in the most of patients (64.3%). L1P was lower than empirically set PEEP in most patients and did not help to optimize gas exchange. PEEP setting at EEEP level in patients with parenchimal respiratory failure increases PaO/FiO, (reflects opening of collapsed alveoli), decreases volume of expired carbon dioxide and decreases lung compliance (reflects overdistenion of opened alveoli). VCO2/EtCO2 ratio decreases (decreased pulmonary perfusion) at PEEP levels more than 16 mbar, which was more than EEEP.

Bicoronary-pulmonary fistulae and severe mitral valve regurgitation – uncommon cause of myocardial ischemia – a case report

Abstract Bicoronary - pulmonary artery fistulae are rare conditions. Their association with mitral valve prolapse is even rarer and randomly reported. This association is important to be recognized in clinical practice because of the differential diagnose problems. Closing the coronary fistulae and mitral valve replacement during the same surgical procedure is probably the optimal management of these patients. We report a case involving the correction of congenital bicoronarypulmonary artery fistulae and mitral valve replacement within the same surgical procedure in a 56 years old female patient with angina and clinical signs of left ventricular failure associating the fistulae to severe mitral regurgitation due to mitral valve prolapse. Past medical history revealed autoimmune thyroiditis, atrial fibrillation, mitral and tricuspid valve regurgitation. At admission physical examination revealed stable vital signs, irregular tachycardia with significant pulse and a mitral regurgitation systolic murmur. ECG showed atrial fibrillation, no ischemia. Echocardiography revealed severe mitral regurgitation, prolapse of anterior and posterior mitral leaflets, moderate tricuspid valve regurgitation, and mild pulmonary hypertension. Coronary angiogram showed no significant lesions of the epicardial vessels but high flow congenital bicoronary-pulmonary fistulae (right coronary artery and left coronary artery to main pulmonary artery). Surgical correction of the congenital bicoronarypulmonary fistulae was performed simultaneously with mitral valve replacement in the same session. Postsurgical evolution was uneventful. Post-procedural ECG showed atrial fibrillation with a controlled heart rate, postoperative echocardiography showed normal functional and normal positioned prosthetic mitral mechanical valve, and rather normal left ventricle function. Coexistence of bicoronary-pulmonary fistulae and mitral valve insufficiency due to prolapse in a symptomatic patient with angina pectoris is a very rare clinical entity. Solving both abnormalities within the same surgical procedure was the optimal management for this patient.

A new diastolic heart sound secondary to free pulmonary regurgitation

Physical examination is recognised as a central pillar in a patient's initial clinical assessment and, in cardiovascular medicine, cardiac auscultation can yield a wealth of valuable information. The first and second heart sounds may be accompanied by a third (S3) or fourth (S4) sound (both diastolic) in various disease states, although S3 may be a normal finding in youth, athletes and the hyperdynamic circulation. These additional sounds do retain clinical relevance in modern practice — for example, the presence or absence of a S3 is commonly used to judge clinical response to treatment in the patient hospitalised due to decompensated heart failure. We report what we believe is the first description of a diastolic heart sound caused by severe regurgitation though a semilunar valve (pulmonary in this case) as opposed to forward flow through an atrioventricular valve. This new sound was detectable clinically, suspected echocardiographically and confirmed by phonocardiography. A 49 year old female was referred for specialist assessment after complaining of palpitations and increasing exertional breathlessness. She had undergone surgical repair of Fallot's tetralogy many years previously, but in a different country and the exact operation details were unavailable. She was not taking any regular medications at the time of referral. There was no known history of respiratory disease. On examination, she was in sinus rhythm with no signs of left ventricular failure. Cardiac auscultation revealed a normal second heart sound but with an additional diastolic sound and a prominent diastolic murmur loudest in the pulmonary region. The patient was thus referred for echocardiographic assessment. Transthoracic 2D-echocardiography demonstrated a moderately dilated right atrium and right ventricle (RV) with moderate tricuspid regurgitation and a dysplastic pulmonary valve with free pulmonary regurgitation (PR) on colour flow Doppler imaging. RV systolic function was only moderately impaired (S3 due to ventricular dysfunction is usually only seen in severe dysfunction). Spectral Doppler analysis revealed a non turbulent jet of laminar retrograde flow across the pulmonary valve with rapidly decaying velocity (due to diastolic equalization of PA and RV diastolic pressures) indicative of severe regurgitation. The additional diastolic sound appreciated on examination had the characteristics of a third heart sound but in fact, when phonocardiography was performed, it correlated precisely with the short and sharp peak retrograde PR velocity (Fig. 1). The patient's cardiac magnetic resonance (CMR) scan confirmed severe PR through a dysplastic pulmonary valve (Fig. 2). The patient subsequently underwent successful surgical pulmonary valve replacement and the additional sound is no longer audible. Patients who have previously undergone surgical repair of tetralogy of Fallot are at risk of developing significant pulmonary regurgitation as a late complication. This is associatedwith impaired exercise capacity [1] and an increased risk of ventricular arrhythmias and sudden death[2]. Echocardiography and CMR are both widely used in the non-invasive investigation of such patients following surgical repair[3]. A new heart sound has not been described for over one hundred years. Here, we present clinically detectable and echocardiographically confirmed evidence of an additional diastolic heart sound attributable to retrograde flow through a semilunar (pulmonary) valve as opposed to antegrade flow across an atrioventricular valve (S3and S4). A third heart sound may be seen in cases of severe atrioventricular valve (mitral or tricuspid) regurgitation but the conventional definition does not include regurgitation through the ventriculo-arterial valves (aortic and pulmonary). Therefore, the mechanism of this sound is not compatible with the current definitions of either the third or fourth heart sounds; hence we propose this is a new sound, which may be best termed a “pulmonary regurgitation sound”. We suggest that auscultation of this diastolic heart sound during routine clinical review should arouse suspicion of significant regurgitation and trigger referral for echocardiography to assess pulmonary valve function. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology (Shewan and Coats 2010;144:1–2).

High incidence of cardiovascular mortality caused by acute and early chronic progressive doxorubicin toxicity: Retrospective analysis of 606 patients.

e18532 Background: Cardiovascular (CVS) system disorders in Poland are responsible for 52% of all deaths and 18% loss of DALY (disability-adjusted life year), compared to 38% and 11% in US respectively. A retrospective analysis was performed to investigate whether the high incidence of CVS disorders in Poland would translate into increased mortality related to cardiotoxicity of doxorubicin based chemotherapy regimens. Methods: Patients (N=606) from 7 hematological centers received the average of 6.7 (1-11) chemotherapy cycles, with cumulative dose of doxorubicin 330 mg/m2 (range 25 – 850); 146 (24%) patients were subjected to further treatment (transplant or radiotherapy) as consolidation or in relapse. Initial cardiac assessment was based on medical histories including echocardiography in 340 (56%) cases. All patients or they families were additionally questioned at the time of analysis about symptoms and signs of left ventricular failure (LVF), or the causes of death. Results: Acute cardiotoxicity was reported in 32 (5%) patients: ten of them died (1.6%), chemotherapy had to be postponed, prematurely terminated or the doses reduced in further 22 cases (3.4%0. The average Left Vetricular Ejection Fraction (LVEF), assessed by echochardiography decreased from 62% (range 40-85%) at diagnosis to 56% (range 20-75%) at the end of treatment (p<0.001). Cardiac impairment was significantly less pronounced in 30 patients treated with liposomal doxorubicin (average LVEF 56.4 and 54.7 respectively, p< 0.001). At the average observation time of 3 years, early chronic progressive cardiotoxicity was responsible for 18 cardiac deaths (2.9%) and further 81 patients (13.3%) required cardiological treatment including 22(3%) cases of acute coronary syndromes. At the time of analysis 40 (43%) patients died due to disease progression. Conclusions: In our retrospection CVS disorders are already the second most common cause of mortality in lymphoma patients (28/92 – 30% of all deaths, 28/606 – 4.6% of all cases). With the expected increased incidence of late chronic progressive cardiotoxicity we would estimate cardiac mortality to be at least doubled at 10 years.

The Use of Nitroprusside in the Treatment of Acute Myocardial Infarction

In 15 patients with acute myocardial infarction, intravenous infusion of the potent vasodilator, nitroprusside, produced an average 50% fall in the elevated left ventricular filling pressure and a modest reduction in arterial pressure (average, 15.5%) without a change in heart rate. Careful dose adjustment in several patients resulted in a significant fall in left ventricular filling pressure with little or no change in arterial pressure. Cardiac output consistently rose during nitroprusside infusion in patients with clinical signs of left ventricular failure or shock and low control cardiac output, whereas output changed little on those patients with normal cardiac index. A fall in pressure time per minute as well as the fall in left ventricular filling pressure indicated a reduction in myocardial oxygen consumption during the vasodilator infusion. Drug infusion was usually accompanied by subjective improvement, including relief of dyspnea and of chest pain, and reduction in ventricular irritability. These data suggest, that vasodilator therapy, by reducing left ventricular afterload, can improve left ventricular performance in patients with acute myocardial infarction. Such treatment may be a rational approach to the management of patients with heart failure, pulmonary edema, or early shock. 1 Commentary Until the publication of this manuscript, little attention was given to the reduction of the peripheral vascular resistance as a method of improving left ventricular function in patients with acute myocardial infarction. The concern about using vasodilators were either that reducing blood pressure will decrease coronary blood flow or because physicians were concerned that a decrease in blood pressure was associated with clinical deterioration. However, Dr Cohn and his colleagues hypothesized that increases in blood pressure in a failing ventricle is harmful and therefore a control decrease in blood pressure may be expected to decrease left ventricular filling pressure. This is the reason why they used nitroprusside in infusion rates between 30 lg ⁄min and 150 lg ⁄min to control blood pressure in these patients and demonstrated a striking fall in left ventricular filling pressure with very little decrease in blood pressure. They also caution that if patients are hypotensive, one should be careful. In this manuscript, the authors put forth a possible mechanism for why nitroprusside may be beneficial to these patients in decreasing left ventricular afterload more than left ventricular preload. In addition, they suggested that compared with inotropic agents, using nitroprusside in patients with acute myocardial infarction reduced left ventricular oxygen consumption. Finally, the authors conclude that nitroprusside may be beneficial in patients with acute pulmonary edema and those with heart failure or early shock. The next historical vignette will discuss the use of nitroprusside in the treatment of refractory heart failure.

High Incidence of Cardiovascular Complications After CHOP-Like Chemotherapy In Lymphoma Patients From Poland – Retrospective Analysis of Polish Lymphoma Research Group (PLRG)

AbstractAbstract 1764 Introduction:Cardiovascular System disorders are among the leading causes of mortality in general population ranging from 10% in Sub Saharan Africa, 38 % in Western Europe and US to even 58% in Eastern Europe and Central Asia. CHOP and it's modifications, with or without Rituximab is the most frequently used chemotherapy regimen for lymphoma patients. Antharcyclin related cardiotoxicity is a well described, dose dependent adverse effect, increasing in frequency with time after therapy, described in 3–5% of patients at 5 years to even 15% of patients at 10 or more years after diagnosis. It was postulated, that higher incidence of cardiovascular mortality, may increase the frequency of anthracyclin cardiotoxicity in Central Europe. Materials and Methods:A retrospective analysis was performed to investigate the frequency of cardiovascular complications after CHOP-like chemotherapy in 428 lymphoma patients treated in 5 oncohematological centers. The median observation time was 3 years (range 0.5–8), therefore it covered acute and early chronic progressive cardiotoxicity. Patients characteristics: average age 55 years (range 18–90), male to female ratio 221/207, clinical stage III/IV – 347 cases (81.5%), general symptoms – 302 cases (71%), large tumor burden defined as it's diameter of 10 cm or more – 41 cases (8.5%), IPI 3–5 in 174 cases (40%). There were 320 patients with DLBCL, 45 – MCL, 32 – FL, 24 – PTCL and 7 – MZL. Initial assessment was based on medical histories including echocardiography in 166 cases (38%). All patients were contacted at the time of analysis, and questioned in detail about symptoms and signs of left ventricular failure (LVF). Results:At a time of diagnosis risk factors for cardiovascular disorders were identified: arterial hypertension (29%), hypercholesterolaemia (13%), diabetes mellitus (8.2%), truncal obesity (17%) and smoking (18.5%). Minority of patients had a previous history of LVF (n=10, 2.3%) and/or myocardial infarction (n=6, 1.4%). The average dose of anthracyclins was 336,5 mg/m2 (range 50 – 680): 391 (91.9%) patients received Doxorubicin, 17 (3.9%) – Nonpegylated Liposomal Doxorubicin, 13 (3,1%) – Farmorubicin and 5 (1.1%) Dauborubicin. Acute cardiotoxicity was reported in 21 cases (4,9%) and resulted in dose reduction, postponing chemotherapy or it's premature termianation. The overall response rate was reasonable, with 297 (69.5%) CR, 83 (19.5%) PR, 10 (2.2%) SD and 38 (8.8%) progressions. At the time of analysis 100 patients (23.4%) relapsed and 63 (14.7%) died: 29 due to disease progression, 24 due to cardiovascular disease, 7 due to infectious complications and 3 due to unknown causes. The average Left Vetricular Ejection Fraction (LVEF), assessed by echochardiography in 166 patients decreased from 63% (range 42–85%) at diagnosis to 56,8% (range 20–72%) at the end of treatment (p<0.001). It corresponded to clinical picture: 51 patients (11.7%) required cardiological treatment after chemotherapy, including 15 cases (3.5%) with myocardial infarction, and further 37 (8.6%) with ischaemic heart pain. Even more revealed signs and symptoms of LVF on direct questioning: exertional dyspnea – 67 (15.7%), pretibial oedema – 72 (16.8%), Nycturia – 48 (11.2%). Conclusions:Our retrospective analysis revealed an important role of anthracyclin cardiotoxicity in lymphoma patients from Poland. At relatively short average time of observation (3 years, range 0.5–8), cardiovascular disorders were the second most common cause of death (24/63 – 38% of deaths, 24/428 – 5.6% of all cases). Further 51 patients (11.7%) required cardiological treatment for at least one life threatening event (myocardial infarction or ischaemic heart pain). [Display omitted] Disclosures:No relevant conflicts of interest to declare.

BET 2: SHOULD WE BE MEASURING TROPONINS IN PATIENTS WITH ACUTE PERICARDITIS?

Report by Rick Body , Specialist Registrar in Emergency Medicine Checked by Craig Ferguson , Specialist Registrar in Emergency Medicine Institution: Manchester Royal Infirmary, Manchester, UK In [stable adult patients...

LEFT VENTRICULAR EJECTION FRACTION AFTER ACUTE MYOCARDIAL INFARCTION.

Objective: (1). To measure and compare Left Ventricular EjectionFraction (LVEF) after acute anterior wall and inferiorwall myocardial Infarction and correlate LVEF with clinical findingsin the patients. (2) To see prevalence of Left Ventricular Failure (LVF) after AMI. Design: Prospective observationalechocardiography based study.Setting: Sheikh Zayed Hospital Lahore. Period: From 2001 to 2002. A total of 60 (sixty)patients of (anterior or inferior) Acute Myocardial infarction (AMI) were included in the study. Patients were divided intwo groups on the basis of anterior myocardial wall MI (AWMI) or inferior myocardial wall MI (IWMI). Echocardiographywas done on all cases and ejection fraction was calculated by applying Simpson’s Rule and patients were examinedat the same time to see the presence of signs of left ventricular failure (LVF). (LVEF) was correlated with the findingsof LVF in these patients. Results: In patients with LVF mean ejection fraction (EF) was 37.13 with standard deviation(SD) of 8.4 %. In patients without failure the mean EF was 56.29% with SD of 3.75. In 30 patients of IWMI, mean EFwas 54.93% with SD of 6.86. In 30 patients of AWMI it was 46.07% with SD of 11.72. In all 60 patients minimum EFwas 30% and maximum was 60% with a mean of 50.50 with SD of 10.52. In AWMI, 53% patients had signs of leftventricular failure. In patients of IWMI, 13.3% had signs of LVF. Conclusions: AWMI causes more decrease in LVEF.LVF is more commonly associated with AWMI than IWMI. There is statistically significant difference in LVEF of patientswith and without LVF.

Impact of beta-myosin heavy chain expression on cardiac function during stress

In failing mouse and human hearts, a shift in myosin heavy chain (MHC) isoform content from alpha to beta can occur. However, the impact of this phenomenon on disease progression is not well understood. Therefore, using transgenic (TG) mice, we tested how a pre-existing shift from alpha- to beta-MHC affects cardiac function under chronic mechanical or pharmacologic cardiovascular stress. Expression of beta-MHC is considered to be energetically favorable, but this might be offset by depressed cardiac function. Transgenic mice with near-complete replacement of the normally predominant alpha- with beta-MHC were subjected to cardiac stress. At baseline, TG mice show moderately reduced cardiac contractile function but are otherwise healthy with normal ventricular morphology. After four weeks of swimming, both TG and non-TG animals showed a 20% increase in left ventricular (LV)/body weight ratios. The TG hearts displayed mildly greater end-diastolic and end-systolic LV diameters than nontransgenic hearts after training, but no signs of LV failure were observed. However, chronic stimulation with isoproterenol resulted in augmented LV hypertrophy with signs of LV decompensation in TG mice. Furthermore, in a post-infarction failure model, TG hearts displayed accelerated LV dilation and a faster decline of shortening fraction. Expression of beta-MHC appears to be disadvantageous to the mice under severe cardiovascular stress, implying that the alpha-->beta-MHC isoform shift observed in cardiac disease may be a maladaptive response.

Independent importance of psychosocial factors for prognosis after myocardial infarction.

As a primary aim it was tested whether the 10-year prognosis after a myocardial infarction is related to psychological stress, lack of social support, anxiety, and/or depressive tendency. A secondary aim was to analyse the prognostic importance of a series of other psychosocial factors as well as interactions. Non-selected patients aged below 65 years with a first infarction (230 men and 45 women) were followed for 10 years with 100% assessment of morbidity and cause-specific mortality. Baseline somatic and psychosocial variables were collected with the aid of standard, validated questionnaires. In multivariate analysis, factors increasing risk for coronary mortality included female sex (hazard ratio, +/- 95% confidence interval) 2.47 (1.06, 5.71), signs of left ventricular failure 3.93 (1.87, 8.26), ventricular dysrhythmia 3 months after the infarction 5.45 (2.21, 13. 42), high depression scores 3.16 (1.38, 7.25) and lack of social support 2.75 (1.29, 5.89). All-cause mortality was significantly related to left ventricular failure, ventricular dysrhythmias, and high depression scores with borderline significance for female sex and social support. Prognosis was affected during the entire follow-up period. It was not significantly associated with age, marital status, education, extra work, mental strain at work or in the marriage, anxiety, dissatisfaction with family life, problems with children, dissatisfaction with the financial situation, life events, anger-in, irritability, type A behaviour, or health locus of control. Incidence of nonfatal infarction was not associated with any of the baseline variables. In addition to known somatic predictors of prognosis after a myocardial infarction, prognosis is strongly influenced by depression and lack of social support, but not to a series of other psychosocial factors. It is recommended to use self-reporting scales to detect prognostically important psychosocial problems.

Recovery of pulmonary diffusing capacity after maximal exercise.

Pulmonary diffusing capacity (DICO), together with spirometric variables, arterial oxygen tension (paO2) and cardiac output were determined before and at intervals after maximal arm cranking, treadmill running and ergometer rowing. Independent of the type of exercise, D1CO increased immediately post-exercise from a median 13.6 (range 7.3-16.3) to 15.1 (9.3-19.6) mmol min-1 kPa-1 (P < 0.01). However, it decreased to 11.6 (6.9-15.5) mmol min-1 kPa-1 (P < 0.01) after 24 h with cardiac output and paO2 at resting values, and D1CO normalized after 20 h. Thoracic electrical impedance at 2.5 and 100 kHz increased slightly post-exercise, indicating a decrease in thoracic fluid balance, and there were no echocardiographic signs of left ventricular failure at the time of the decrease in D1CO. Also, active muscle (limb) circumference and volume, and an increase in haematocrit from 43.8 (38.0-47.0) to 47.1 (42.7-49.8) (P < 0.01), had normalized at the time of the decrease in D1CO. Vital capacity, forced vital capacity, forced expiratory volume in 1 s, peak and peak mid-expiratory flows did not change. However, total lung capacity increased from 6.8 (5.0-7.6) to 7.0 (5.1-7.8) litres (P < 0.05) immediately after exercise and remained elevated at 6.9 (5.1-8.7) litres (P < 0.05) when a decrease in D1CO was noted. The results demonstrate that independent of the type of maximal exercise, an approximate 15% reduction in D1CO takes place 2-3 h post-exercise, which normalizes during the following day of recovery.

Effects of subsequent pregnancy on left ventricular function in peripartum cardiomyopathy

Pregnancy has been discouraged in patients with peripartum cardiomyopathy (PPCM) to avoid the risk of precipitating recurrent or progressive left ventricular dysfunction. We assessed left ventricular size and contractile function using echocardiography in four PPCM patients prior to pregnancy, during the third trimester, and a mean of 6 weeks postpartum. Left ventricular mean diameters at end diastole and at end systole prior to pregnancy (5.2 ± 0.3 and 3.0 ± 0.2 cm, respectively) did not change during pregnancy (5.2 ± 0.3 and 3.1 ± 0.2 cm). Similarly, left ventricular fractional shortening did not alter significantly during pregnancy or postpartum. Furthermore, no patient developed any symptoms or signs of left ventricular failure. All patients had normal babies, including one who had twins. We conclude that PPCM patients whose left ventricular function returns to normal may undertake further pregnancy with a normal fetal outcome and a low risk of recurrent left ventricular dysfunction.