Ventricular Dysrhythmias Research Articles

Toluene Inhalant Addiction and Cardiac Functions in Young Adults: A Comparison of Electrocardiographic and Echocardiographic Parameters.

Volatile substance (thinner) addiction can cause serious cardiac events, such as malignant ventricular arrhythmias, acute coronary syndromes, sudden death syndrome, and dilated cardiomyopathy, as reported in many case studies. We aimed to find echocardiographic and electrocardiographic parameters that could foresee these adverse outcomes in clinical settings. We enrolled 32 healthy young adult patients with at least 1 year of thinner addiction and no cardiac symptoms. We also recruited a control group of 30 healthy individuals without any medical problems. Both groups received standard echocardiography and ECG tests. We analyzed the following echocardiographic parameters: LVEDd (left ventricular end-diastolic diameter), LVESd (left ventricular end-systolic diameter), mitral valve EF slope, E/A ratio, and aortic and pulmonary valve VTI (velocity time integral). We also measured the corrected (QTc), uncorrected QT intervals, and widest P-wave values in the ECG. We used the SPSS 13 software for statistical analysis. The echocardiographic findings did not differ significantly between the groups. However, the ECG results showed that the thinner addicts had higher values of corrected (QTc), uncorrected QT intervals, and widest P-wave values than the control group, according to Mann-Whitney U and Student's T test. Corrected QT (QTc) and P-wave duration are increased in individuals with a thinner addiction. These findings may suggest a higher risk of sudden cardiac death, atrial, and ventricular dysrhythmias in the future.

Utility of the AngelMed Guardian System in myocardial bridging: a case report

BackgroundMyocardial bridging (MB) is a known congenital anomaly in which a segment of the coronary artery transverses from the epicardium through the myocardium. MB may clinically manifest as recurrent angina, acute coronary syndrome, ventricular dysrhythmia, and even sudden cardiac death. On electrocardiogram (EKG), MB can present with findings consistent with significant ST-segment changes. The AngelMed Guardian System (the Guardian device) was developed in an effort to optimize the time from the onset of myocardial ischemia to intervention. The device analyzes myocardial electrical changes and alerts the patient to seek emergent medical evaluation if an acute ST-segment deviation is detected. We describe the first documented case of the Guardian device detecting acute ST-segment changes secondary to myocardial bridging.Case PresentationA 50-year-old male, with a history of percutaneous coronary intervention of the proximal left anterior descending (LAD) artery, presented to his cardiologist’s office with reports of recurrent, atypical chest pain. The Guardian device was implanted. One month after implantation, the patient experienced chest pain and was alerted by the Guardian device to seek emergent medical evaluation. Initial EKG and high-sensitivity troponins were negative for acute ischemia. Guardian device interrogation revealed significant ST depressions, encouraging further ischemic evaluation. The exercise myocardial perfusion imaging revealed an apical reversible defect. Left heart catheterization revealed a large segment of mid-LAD MB with the patient’s previous LAD stent noted to be widely patent along with no evidence of new obstructive coronary disease. Following the identification of the MB, medication regimen adjusted and the patient denied recurrence of chest pain or Guardian alerts.ConclusionsWe describe the first documented case of the Guardian device detecting acute ST-segment changes that were secondary to myocardial bridging. The Guardian device appropriately documented an ischemic event not appreciated with initial EKG or troponin testing. With the assistance of the Guardian device, we were able to rapidly identify MB as the cause for the ischemic EKG changes and subsequent abnormal stress test, optimize medical management, and prevent recurrent atypical chest pain along with office and hospital visits.

Evolving trends of pharmaceutical poisonings associated with QRS complex prolongation

Introduction Tricyclic antidepressants often cause drug-induced QRS complex prolongation in overdose but are now less commonly prescribed. We sought to determine, among a contemporary cohort of patients, the pharmaceuticals independently associated with QRS complex prolongation in acute overdose. Methods We performed secondary analysis of data from the Toxicology Investigators Consortium (ToxIC) Core Registry. We included adult patients presenting from January 2016 through March 2023 with acute or acute-on-chronic pharmaceutical exposures. The primary outcome was QRS complex prolongation >0.12 s. Secondary outcomes included cardiac arrest, death, ventricular dysrhythmia, intensive care unit admission, initiation of vasopressors, and treatment with sodium bicarbonate. We used a multivariable logistic regression model with QRS complex prolongation as the outcome and individual pharmaceuticals of interest as independent variables. We assessed yearly trends of the contribution of relevant pharmaceuticals to QRS complex prolongation since 2016. Results Of 11,945 patients in the total cohort (median age 37 years, 6,652 [55.7%] female), 366 (3.1%) developed QRS complex prolongation. Of 9,417 patients included in the model, 290 (3.1%) developed QRS complex prolongation. Amitriptyline, nortriptyline, doxepin, imipramine, noxiptiline, bupropion, flecainide, carvedilol, propranolol, diphenhydramine, and lamotrigine poisonings were independent predictors of QRS complex prolongation. Flecainide poisoning conferred the greatest odds of QRS complex prolongation (OR 574.1; 95% CI: 88.3–12,747). The contribution of tricyclic antidepressants to QRS complex prolongation decreased from 38.8% to 17.6% of all patients with QRS complex prolongation from 2016 to 2022. In 2022, the proportion of QRS complex prolongation from diphenhydramine (20.6%) surpassed that of tricyclic antidepressants. Discussion This study provides insights into contemporary pharmaceutical poisoning associated with QRS complex prolongation. Tricyclic antidepressants remain clinically relevant exposures but are no longer the most common cause of drug-induced QRS complex prolongation. Conclusions Bupropion, diphenhydramine, and antidysrhythmics are increasingly common causes of QRS complex prolongation, each associated with numerous severe outcomes in poisoning. Greater safety measures to protect patients from cardiovascular toxicity from these pharmaceuticals are warranted.

The Role of Ranolazine in the Treatment of Ventricular Tachycardia and Atrial Fibrillation: A Narrative Review of the Clinical Evidence.

Cardiac arrhythmias are among the leading causes of morbidity and mortality worldwide. While antiarrhythmic drugs traditionally represent the first-line management strategy, their use is often limited by profound proarrhythmic effects. Several studies, including randomized control trials (RCTs), have demonstrated the antiarrhythmic efficacy of ranolazine, which is registered as an antianginal agent, while also establishing its safety profile. This review compiles clinical evidence investigating the antiarrhythmic properties of ranolazine, focusing primarily on ventricular tachycardia (VT) and atrial fibrillation (AF), as they are common rhythm abnormalities with serious complications. Data from RCTs indicate that ranolazine reduces VT incidence, although this effect is not universal. Therefore, we attempt to better describe the patient population that gains the most benefit from ranolazine due to VT suppression. Additionally, ranolazine is known to enhance the conversion rate of AF to sinus rhythm when combined with other antiarrhythmic drugs such as amiodarone, highlighting its synergistic effect in the atrium without provoking ventricular dysrhythmias. Despite the heterogeneity in the currently available data, ranolazine appears to be an effective and safe option for the management of various arrhythmias.

Predicting adverse cardiovascular events in emergency department patients with bupropion overdose.

Bupropion toxicity can lead to adverse cardiovascular events (ACVE), but delayed onset of toxicity makes risk stratification difficult. This study aimed to validate previously defined predictors of ACVE and identify novel predictors among patients presenting to the emergency department (ED) after bupropion overdose. This secondary analysis of prospective data from the Toxicology Investigators Consortium Core Registry analyzed adult acute or acute-on-chronic bupropion exposures from 2015 to 2018. The primary outcome was ACVE (any of the following: myocardial injury, shock, ventricular dysrhythmia, or cardiac arrest). Potential predictors of ACVE included previously derived predictors in the overall drug overdose population (prior cardiac disease, initial serum bicarbonate < 20 mEq/L, and initial QTc ≥ 500 ms), exposure circumstances, and initial serum lactate value. Candidate predictors were evaluated using univariate analysis and multivariable regression modeling. Receiver operator characteristic curves were used to derive optimal cutoff points for novel predictors, and prognostic test characteristics were calculated. Of 355 patients analyzed, ACVE occurred in 34 (9.6%) patients. Initial serum bicarbonate < 20 mEq/L (adjusted odds ratio [aOR] 4.42, 95% confidence interval [CI] 1.94-10.0) and initial QTc ≥ 500 ms (aOR 2.52, 95% CI 1.01-6.09) independently predicted ACVE. Exposure circumstances did not predict ACVE. Initial serum lactate > 5.2 mmol/L independently predicted ACVE (aOR 12.2, 95% CI 2.50-75.2) and was 90.7% specific with 80.3% negative predictive value. Metabolic acidosis and QTc prolongation were validated as predictors of ACVE in ED patients with bupropion overdose. Serum lactate elevation was strongly predictive of ACVE in this study and warrants further investigation.

Congenital Long QT Syndrome Unmasked by Albuterol in an Adolescent with Asthma

BackgroundPatients with congenital long QT syndrome (LQTS) are prone to ventricular dysrhythmia but may be initially asymptomatic with a normal QTc interval on resting electrocardiogram (ECG). Albuterol is listed as a medication that poses a “special risk” to patients with congenital LQTS, but its effects have been rarely described. We present a case of previously unknown, asymptomatic congenital LQTS unmasked by albuterol in an adolescent with asthma. Case ReportA 12-year-old girl with a history of asthma presented to the emergency department (ED) with shortness of breath, wheezing, and tachycardia for 24 h, consistent with acute asthma exacerbation. She received two doses of her home albuterol inhaler 2 h prior to presentation. Initial ECG demonstrated a QTc of 619 ms. Her remaining history, clinical examination, and laboratory workup, including electrolytes, were unremarkable. She was observed with cardiac monitoring before being discharged from the ED in stable condition for next-day outpatient pediatric cardiology follow-up. Resting office ECGs revealed QTcs from 440–470 ms. Exercise stress test revealed QTc prolongation of 520 ms and 500 ms at minute-2 and minute-4 of recovery, respectively. Genetic testing revealed heterozygous pathogenic variants in KCNQ1, consistent with type 1 LQTS. Why Should an Emergency Physician Be Aware of This?Albuterol may be a cause of marked QTc prolongation in ED patients with underlying congenital LQTS, which can be a diagnostic clue in previously unidentified patients. Extreme QTc prolongation also serves as an indication in the ED for Cardiology consultation, laboratory evaluation for electrolyte imbalances, and observation with cardiac monitoring.

Extracorporeal Membrane Oxygenation: Rescue Therapy in Pediatric Bupropion Cardiotoxicity

Abstract Objective Our objective was to describe clinical characteristics and course of pediatric bupropion ingestions requiring extracorporeal membrane oxygenation (ECMO) life support. Desgin The study included a retrospective cohort of patients ≤18 years of age reported to a regional poison control (PC) system covering three states in the upper Midwest United States. All bupropion exposures ≤18 years of age, coded as receiving ECMO to treat toxicity, were included. Clinical presentation and management including ECMO are presented as descriptive statistics. Results During the study period, 4,951 bupropion exposures were reported; 1,145 (23.1%) were children. Nine patients were coded as undergoing ECMO; four (44.4%) were ≤18 years of age (median 16, range 14–17). All were treated with venoarterial ECMO. The median time from ingestion to presentation was 2.25 hours (range: 1–3.5). Median first systolic blood pressure and pulse were 100 mm Hg (range: 70–124) and 119.5 (range: 70–175). The median time from ingestion to ECMO was 17.63 hours (range: 7.25–33.75); median number of vasopressors was 2.5 (range: 2–3). All experienced multiple seizures, ventricular dysrhythmias, and hypotension. Three of four sustained cardiac arrest. All but one required transfer to an ECMO-capable facility for definitive care. Three patients survived with full neurologic recovery; one died. Conclusion Pediatric bupropion cases requiring ECMO were rare in this study. Time to initiation and duration of EMCO suggest that the variable onset of hemodynamic instability may delay ECMO initiation. It is incumbent on PCs and medical toxicologists to educate prescribers and pediatricians about bupropion's potential lethality and to consider early transfer to an ECMO center.

The role for ambulatory electrocardiogram monitoring in the diagnosis and prognostication of Brugada syndrome: a sub-study of the Rare Arrhythmia Syndrome Evaluation (RASE) Brugada study.

Brugada syndrome (BrS) diagnosis and risk stratification rely on the presence of a spontaneous type 1 (spT1) electrocardiogram (ECG) pattern; however, its spontaneous fluctuations may lead to misdiagnosis and risk underestimation. This study aims to assess the role for repeat high precordial lead (HPL) resting and ambulatory ECG monitoring in identifying a spT1, and evaluate its prognostic role. HPL resting and ambulatory monitoring ECGs of BrS subjects were reviewed retrospectively, and the presence of a spT1 associated with ventricular dysrhythmias and sudden cardiac death (SCD). Three-hundred and fifty-eight subjects (77 with spT1 pattern at presentation, Group 1, and 281 without, Group 2) were included. In total, 1651 resting HPL resting and 621 ambulatory monitoring ECGs were available for review, or adequately described. Over a median follow-up of 72 months (interquartile range - IQR - 75), 42/77 (55%) subjects in Group 1 showed a spT1 in at least one ECG. In Group 2, 36/281 subjects (13%) had a newly detected spT1 (1.9 per 100 person-year) and 23 on an HPL ambulatory recording (8%). Seven previously asymptomatic subjects, five of whom had a spT1 (four at presentation and one at follow-up), experienced arrhythmic events; survival analysis indicated that a spT1, either at presentation or during lifetime, was associated with events. Univariate models showed that a spT1 was consistently associated with increased risk [spT1 at presentation: hazard ratio (HR) 6.3, 95% confidence interval (CI) 1.4-28, P = 0.016; spT1 at follow-up: HR 3.1, 95% CI 1.3-7.2, P = 0.008]. Repeated ECG evaluation and HPL ambulatory monitoring are vital in identifying transient spT1 Brugada pattern and its associated risk.

Single intravenous dose ondansetron induces QT prolongation in adult emergency department patients: a prospective observational study

BackgroundOndansetron is one of the most commonly used drugs in the emergency department (ED) for treating nausea and vomiting, particularly in intravenous (IV) form. Nevertheless, it has been shown to prolong QT interval and increase the risk of ventricular dysrhythmias. This study evaluated the associations between single IV ondansetron dosage and subsequent QTc prolongation in the ED.MethodsIn this prospective observational study, a total number of 106 patients presenting to the ED in a 3-month period with nausea and vomiting treated with IV ondansetron were enrolled. QT and QTc intervals were measured at baseline (QT0 and QTc0), and 60 min (QT60 and QTc60) following a single-dose administration of ondansetron at 4 or 8 mg doses. To evaluate the predictive ability of these variables, we employed receiver operating characteristic (ROC) curve analyses.ResultsThe predictive models for QTc prolongation 1-hour post-ondansetron administration showed the following: at baseline, the area under curve of 0.70 for QT, 0.71 for QTc, and 0.64 for dosage. Conversely, a QTc0 = 375 msec indicated a QTc60 > 480 msec with a specificity of 97%. Additionally, a QTc0 of 400 msec had a sensitivity of 100% in predicting a QTc60 < 480 msec, while a QTc0 > 460 msec predicted a QTc60 > 480 msec with a specificity of 98%. Moreover, 8 mg doses were associated with higher rates of QTc60 prolongation, while 4 mg doses favored maintaining QTc60 within normal limits.ConclusionsOur study demonstrates the predictive capacity of QT0, QTc0, and ondansetron dosage in forecasting QTc60 prolongation (> 480 msec) post-ondansetron administration. These findings advocate for their incorporation into clinical protocols to enhance safety monitoring in adult ED patients.

Clinical outcomes associated with orphenadrine deliberate self-poisoning: a retrospective poisons centre study

Introduction Orphenadrine overdoses can cause antimuscarinic toxicity, respiratory failure, refractory seizures and cardiotoxicity. The dose–toxicity relationship is poorly defined. Orphenadrine is marketed as immediate and sustained release formulations, and it is not known how the formulation impacts on toxicity. We determined the clinical toxicity of orphenadrine in patients referred to a regional poisons centre. Methods Retrospective case series of patients in New South Wales with orphenadrine deliberate self-poisoning from January 2016 to April 2022 referred to the New South Wales Poisons Information Centre. Demographics, history of exposure, treatment and outcomes were extracted from clinical databases. Receiver-operating characteristic curves were constructed to determine thresholds predicting toxicity. Results Forty-eight patients were identified, with information on clinical outcomes in 46 patients and doses in 41 patients. All patients were older than 12 years. The median orphenadrine dose was 770 mg (range 210–10,000 mg), 59 per cent as the immediate release formulation, and 67 per cent reported coingestants. Doses of sustained release formulations were significantly greater than immediate release formulations, median 2,750 mg versus 595 mg. Common clinical features were drowsiness (59 per cent), sinus tachycardia (37 per cent) and confusion (33 per cent). Three patients had mild hypotension, three were intubated for coma, and two had seizures; no patients suffered ventricular dysrhythmias. All patients survived, with 75 per cent being medically cleared within 24 hours of presentation. A dose–toxicity relationship was observed, but conclusions are limited by the small number of cases with moderate or severe toxicity. Discussion All patients survived, and severe cardiac and neurological toxicity were not observed. This contrasts to published case reports noting severe poisoning at similar or lower doses. Formulation may have an impact on outcomes, with lesser toxicity from sustained release products. Conclusions Orphenadrine doses up to 10 g were associated with antimuscarinic toxicity and sedation, but not severe cardiotoxicity. More research exploring the effect of dose and formulation on outcomes is required.

The role of QRS complex prolongation in predicting severe toxicity in single-xenobiotic overdose

Objective The QRS complex duration is commonly used to prognosticate severity, predict outcomes, and indicate treatment in overdose. However, literature to support this practice is mixed in tricyclic antidepressant overdoses and absent in non-tricyclic antidepressant overdoses. Our objective was to assess the validity of QRS complex duration as a prognostic marker in overdose. Methods This was a secondary analysis of cases reported to the Toxicology Investigators Consortium between January 1, 2010, and December 31, 2022. Cases were assessed to determine the six xenobiotics most associated with QRS complex prolongation. All cases involving these six xenobiotics, regardless of QRS complex duration, constituted the study cohort. Inclusion criteria were cases of patients older than 12 years old with single-xenobiotic exposures. Clinical outcomes evaluated were seizure, ventricular dysrhythmia, metabolic acidosis, and death. Results Of 94,939 total cases, diphenhydramine, amitriptyline, bupropion, quetiapine, nortriptyline, and cocaine were most associated with QRS complex prolongation. Inclusion criteria were met by 4,655 cases of exposure to these xenobiotics. QRS complex prolongation was associated with increased odds ratio of seizure in all included xenobiotics, of ventricular dysrhythmia in all included xenobiotics except nortriptyline, and of metabolic acidosis or death in all included xenobiotics except nortriptyline and quetiapine. A normal QRS complex duration had a negative predictive value of greater than or equal to 93.0 percent of developing metabolic acidosis and 98.0 percent of developing a ventricular dysrhythmia or death from the xenobiotics studied. Discussion This study demonstrates that patients with QRS complex prolongation from all six xenobiotics studied had an increased prevalence and odds of developing severe outcomes. Furthermore, patients who did not develop QRS complex prolongation were unlikely to develop a ventricular dysrhythmia, metabolic acidosis, or death. These findings were noted in six xenobiotics that mechanistically can cause QRS complex prolongation through sodium channel or gap junction inhibition. Conclusion Identification of patients at risk for severe outcomes after overdose can be aided by measuring the QRS complex duration. If prospectively validated, these outcomes have implications on risk stratification, disposition level of care, and appropriateness of treatments.

Perioperative Dysrhythmias in Adult Patients for Non Cardiac Surgery: A Prospective Cohort Study

Introduction: The vulnerable perioperative period is prone to the development of a heterogeneous group of conditions characterised by abnormal electrical activity in the heart, termed as cardiac dysrhythmias. Aim: To determine the incidence of dysrhythmias in the perioperative period, identify predisposing factors, evaluate the effect of anaesthesia, analyse haemodynamic consequences, and document the treatment provided. Materials and Methods: A prospective cohort study involving 9666 adult patients undergoing non cardiac surgery was conducted in the Department of Anaesthesiology at Lokmanya Tilak Municipal College and General Hospital, Sion, Mumbai, Maharsahtra, India from January 2012 to December 2013. Parameters studied included preoperative clinical data (history, examination, and relevant investigations), type of anaesthesia, occurrence of dysrhythmias, and clinical outcomes of persistent dysrhythmias or those requiring treatment. Data was collected prospectively and analysed using Statistical Package for Social Sciences (SPSS) software version 15.0. Results: The overall incidence of dysrhythmias was 1.2%. Consistent factors included age over 40 years (68.1%), male gender (52.59%), gastrointestinal and orthopaedic procedures (65.5%), preoperative hypertension (25%), and patients receiving general anaesthesia (61.2%). Most patients were classified as American Soceity of Anesthesiologists (ASA) Class-I and II (93.97%) and underwent elective surgery (61.21%). The majority (81.89%) of dysrhythmias occurred intraoperatively and were ventricular in origin (68.97%). Unstable haemodynamic conditions [Systolic Blood Pressure (SBP) &lt;90 mmHg, Heart Rate (HR) &lt;50 /min and/or Ventricular Premature Contraction (VPCs) &gt;5/min or multifocal VPCs)] were observed in 56.9% of patients. Of patients with ventricular dysrhythmias, 57% exhibited unstable haemodynamics. Treatment was provided to 84.48% of patients, with 74.14% responding positively, leading to the termination of dysrhythmias. Anticholinergics were used in 40.52% of treatment modalities. The majority of dysrhythmias were transient 80 (68.9%) patients, and 83 of patients had a favourable outcome. Unfortunately, 5 (6.9%) of patients could not be revived, with three patients 3 (2.5%) succumbing in the operating room. Mortality was not directly linked to the dysrhythmia but was due to underlying causes. Conclusion: Transient intraoperative ventricular cardiac dysrhythmias are common in adult patients undergoing noncardiac surgeries. Therefore, it is crucial to identify highrisk patients, analyse contributing factors, and promptly correct issues under expert medical guidance.

Abstract 17979: Cardiogenic Shock - The Index Presentation of Cardiac Sarcoidosis; Challenges in Diagnosis and Management

Cardiac sarcoidosis often presents with ventricular dysrhythmias but can manifest as cardiogenic shock. We discuss a patient who presented with the latter requiring escalating support serving multiple challenges including making a definitive diagnosis &amp; its management. 59 year-old male presented in cardiogenic shock requiring inotropic assisted diuresis. Due to continued clinical decline, he underwent Impella 5.5 placement for mechanical circulatory support (MCS). Echocardiogram showed ejection fraction of 25-30% with global hypokinesis. Reviewing his prior medical records, revealed a lymph node biopsy with non-caseating granulomas 5 years ago concerning for sarcoidosis. Due to his dependence on temporary MCS, we were unable to confirm with a cardiac MRI. Knowing that FDG-PET can only elucidate the site of active sarcoidosis, it was pursued as the only viable imaging modality. His FDG-PET scan was positive for involvement of the inferior wall &amp; right atrium. He was placed on immunosuppression with mycophenolate mofetil &amp; prednisone. During his hospitalization, serial FDG-PET scans were performed showing resolution of active inflammation which allowed for weaning of immunosuppressants. Despite treating his active disease, his course was complicated by worsening renal failure requiring hemodialysis, MCS-dependent heart failure, placement of a left ventricular assist device (LVAD) and fungemia. Following treatment, he was placed on lifelong suppression with fluconazole. Given his renal failure and infection, he was not a candidate for heart transplant. His infection also precluded our ability for long-term immunosuppression. There are no guidelines or detailed pathways on managing cardiogenic shock in patients with cardiac sarcoidosis. Our case highlights the challenges faced when shock is the index presentation as it increases the risk of end organ damage which therefore requires expedited work up for destination therapy. Though LVAD is a viable option for patients with cardiac sarcoidosis, duration of immunosuppression, long term follow up for scar, risk and treatment of infection in patients that are not transplant candidates is largely unexplored. More studies are needed to help guide management of shock in this patient population.

A Comparative Study of Lung-protective Effects of Melatonin Versus Curcumin in Amiodarone Treated Adult Male Albino rats

Amiodarone (AMR) is a very powerful and efficient anti-arrhythmic agent since it outperforms other treatments in preventing and treating ventricular and supraventricular dysrhythmias. Melatonin is produced by a variety of organs, including the pineal gland. It has anti-oxidant and anti-inflammatory properties. Curcumin provides a variety of different health benefits and has been demonstrated to have considerable antioxidant action. The purpose of this study was to look into and evaluate the preventive benefits of melatonin and curcumin against AMR-induced lung damage.60 adult male albino rats were utilized in this study divided equally into 5 main groups: (control with no drugs, sham divided into 2 subgroups sham1 receiving 500Ug/kg body weight (BW) of melatonin and sham2 receiving 200 mg/kg BW of curcumin, AMR treated group receiving 40 mg/kg BW of AMR orally, AMR with melatonin group receiving500Ug/kg body weight (BW) of melatonin and40 mg/kg BW of AMR, and AMR with curcumin group receiving 200 mg/kg BW of curcumin and 40 mg/kg BW of AMR). this study was continued for 6 weeks. The lung tissue was processed for histopathological and biochemical evaluation at the end of the experiment and revealed significant elevations in inflammatory cytokine (il6) and oxidative parameters, lung alterations with fibrosis and marked cellular infiltration in the AMR-treated group. Yet treatment with melatonin and curcumin improved fibrosis detected by decreased area of positive TGF-β1 staining and lower number of stained macrophages by CD68 along with improving the antioxidant status of the tissue. Thus melatonin and curcumin had a protective effect over AMR-induced fibrosis.

Yamaguchi Sendromu: Akut Koroner Sendrom Ayırıcı Tanısında Zor Bir Tanı

Apical hypertrophic cardiomyopathy (ApHCM) (Yamaguchi Syndrome) with hypertrophy of the ventricular apex constitutes 8% of the hypertrophic cardiomyopathies (HCMs). ApHCM can cause ventricular malignant dysrhythmias, atrial fibrillation, and ischemic chest pain. Definitive diagnosis is made by electrocardiography (ECG) and transthoracic echocardiography. A 73-year-old male patient was admitted to the emergency department with chest pain. The patient's vital signs were within the normal range. In the ECG, there were giant negative T wave in leads V4-5-6, 0.5 mm ST segment depression, and left ventricular hypertrophy in the inferior derivations. The left ventricular apex thickness was measured as 14 mm (reference range: 6-11). Although the HEART score was 4, the preliminary diagnosis of the patient was determined as ApHCM. Beta-blocker and antiplatelet therapy were started. The mortality and morbidity rates of ApHCM are higher among HCMs. Clinicians should be aware of such ECG and echocardiography findings to prevent possible morbidity and mortality.

Dysrhythmia in acute coronary syndrome patients undergoing coronary artery bypass grafting surgery at hanoi heart hospital

Objectives: Many studies have demonstrated arrhythmias were common in acute coronary syndrome and coronary artery bypass grafting surgery. Although the most of these arrhythmias were transient and have a benign course, but it may represent a significant source of morbidity and mortality. This study aimed to establish the temporal change pattern of arrhythmias observed to determine the incidence and characteristics of dysrhythmia.&#x0D; Methods: A prospective method was used to study 52 consecutive patients with acute coronary syndrome who were assessed using 24-hour Holter recordings before CABG and 1 week, 3 months, and 6 months after the surgery from June 2016 to August 2018 at Hanoi Heart Hospital.&#x0D; Results: New appearance of atrial fibrillation after coronary artery bypass grafting surgery increased by time, at 7 days was 17.3%, after 3 and 6 months were 10 - 18.4%. Percentage of ventricular dysrhythmias was highest before surgery 8.67%, decreased after surgery and lowest after 6 months. The rate of short ventricular tachycardia at 7 days after surgery was highest (11.8%), followed by the preoperative period (3.8%), decreased and disappeared after 6 months. Ventricular arrhythmias with Lown (grade &gt; 3) preoperative was 44.2%, increased at 7 days postop was 51.9% and decreased postop 3 - 6 month (28 - 20%).&#x0D; Conclusion: New appearances of atrial fibrillation after coronary artery bypass grafting surgery increased by time. Dysrhythmia was acutely affected by myocardial ischemia and coronary artery bypass grafting surgery.

Are antimuscarinic effects common in hydroxyzine overdose? A cohort analysis of antimuscarinic effects in hydroxyzine and diphenhydramine-poisoned patients

Introduction Exposures to hydroxyzine, a first-generation H1 antihistamine, have increased rapidly over the last two decades. Many assumptions about hydroxyzine poisoning are based on other antihistamines, like diphenhydramine. However, the receptor affinities of hydroxazine suggest that there should be fewer antimuscarinic findings than diphenhydramine. Methods This was a cohort study that compared hydroxyzine and diphenhydramine exposures reported to the National Poison Data System between January 1, 2000, and December 31, 2020, and the Toxicologic Investigators Consortium Core Registry between January 1, 2010, and December 31, 2020. The primary outcome was to assess for antimuscarinic findings in hydroxyzine-poisoned patients, using diphenhydramine-poisoned patients as a comparison group. The secondary outcomes were to assess for markers of overall toxicity. Inclusion criteria were single-substance exposures with known outcomes. Exclusion criteria for National Poison Data System exposures were chronic exposures, unintentional exposures, and patients younger than 12 years old. There were no exclusion criteria for exposures reported to the Toxicologic Investigators Consortium Core Registry. Results There were 17,265 hydroxyzine and 102,354 diphenhydramine exposures reported to the National Poison Data System and 134 hydroxyzine and 1,484 diphenhydramine exposures reported to the Toxicologic Investigators Consortium Core Registry that met inclusion criteria. In both datasets, hydroxyzine-poisoned patients had lower rates and relative risk of developing antimuscarinic findings or receiving physostigmine, with the exception of hyperthermia in the Toxicologic Investigators Consortium Core Registry dataset. Coma/central nervous system depression (major), respiratory depression, seizures, ventricular dysrhythmias, intubation, and benzodiazepine administration were less likely in hydroxyzine-poisoned patients, but central nervous system depression (mild) was more likely in exposures reported to the National Poison Data System. The mortality in hydroxyzine-poisoned patients was rare: 0.02% and 0.8% of exposures reported to the National Poison Data System and Toxicologic Investigators Consortium Core Registry, respectively. Discussion The clinical manifestations of hydroxyzine exposures are consistent with the pharmacology of hydroxazine. The clinical effects were consistent across two United States national datasets. Clinicians should not generalize the illness script of diphenhydramine exposures to hydroxyzine exposures. Conclusions Hydroxyzine-poisoned patients were less likely to develop antimuscarinic findings than diphenhydramine-poisoned patients. Hydroxyzine-poisoned patients were more likely to have mild central nervous system depression than an antimuscarinic toxidrome.

Intra-Cardiac Arrest Use of Stellate Ganglion Block for Refractory Ventricular Tachycardia

BackgroundRefractory ventricular dysrhythmia, or electrical storm, is a cardiac condition consisting of three or more episodes of ventricular dysrhythmia resistant to treatment within a 24-hour period. These dysrhythmias carry high morbidity and mortality if not diagnosed and abated promptly. When traditional resuscitative algorithms fail to return a patient to a perfusing rhythm, providers need to consider other, more novel techniques to terminate these dangerous dysrhythmias. One approach is the use of a stellate ganglion block, which has been documented in the literature only a handful of times for its resuscitative use in cardiac arrest. Case SeriesThis case series details two cases from an urban emergency department (ED) in a large metropolitan city, where the use of ultrasound-guided stellate ganglion blocks during cardiac arrest provided successful ablation of the tachydysrhythmia. The first case involves a patient who went into cardiac arrest while in the ED and was found to be in refractory pulseless ventricular tachycardiawhile. The second case describes a patient who went into a witnessed out-of-hospital cardiac arrest while with emergency medical services. Why Should an Emergency Physician Be Aware of This?The stellate ganglion block is a procedure currently being used as a treatment modality for a variety of neurologic, psychological, and cardiac conditions. This intervention may provide a viable and lifesaving option for emergency physicians to adopt when traditional resuscitative algorithms fail to break resistant ventricular tachydysrhythmias.

The Effect of Continuous Care Program on the Self-Efficacy of Patients with Implantable Cardioverter Defibrillator: A Randomized Control Trial.

The majority of cardiac disorders resulting from ventricular dysrhythmias are fatal. The Implantable Cardioverter Defibrillator (ICD) is one of the most common treatments of ventricular dysrhythmias. Despite the benefits of ICD in preserving life, patients with ICD experience adverse physical, psychological, and social consequences. This study investigated the effects of the continuous care program on self-efficacy in patients with ICD. The present study was a randomized clinical trial. Based on the inclusion criteria, 80 patients attending an educational cardiovascular center in Tehran during 2017-2018, were randomly assigned to two intervention and control groups (40 in each). The intervention included the continuous care program, an educational session, and a follow-up program undertaken for the patients receiving the ICD. The control group received routine care. Self-efficacy was then measured by ICD (SE-ICD and OE-ICD) questionnaires and compared between the two groups. The results showed no difference between the two groups before the intervention (p > 0.05). However, there was a significant difference in the mean self-efficacy score between the two groups after the intervention, being significantly higher in the intervention group (t77 = 4.9, p < 0.001). The results of the present study indicated that providing a continuous care program can increase self-efficacy in patients with ICD and can be used as an effective model in the nursing care of patients with ICD.

Acute oleander poisoning treated successfully without Fab fragments- a case series and literature review

ABSTRACT Background- Nerium oleander (common oleander grown as an ornamental plant) and Cerbera Thevetia (yellow oleander grows wildly on the roadside). All parts of these plants, including nectar, are potentially lethal. Suicidal poisoning by the products of these plants is a toxicologic emergency in tropical and subtropical regions. They contain cardiac glycosides, namely Oleandrin, Oleandrigenin, Nerifolin, ThevetinA, and ThevetinB, which act like digoxin in addition to gastrointestinal symptoms. Ingestion of oleander results in nausea, vomiting, abdominal pain, diarrhoea, dysrhythmias, and hyperkalemia. Cardiac toxicity includes a variety of ventricular dysrhythmias and A-V Blocks, muscular twitching, tetanic spasms, lockjaw, coma and respiratory paralysis. The cause of death is usually cardiogenic shock and respiratory arrest. Some cases have been reported with acute kidney injury and hepatic damage. Case report – We have successfully managed 3 cases of acute oleander poisoning. All three patients were young and did not have comorbid conditions. 2 patients presented with mainly abdominal pain and vomiting and had hyperkalemia. The third patient had symptomatic bradycardia and several episodes of vomiting. Most cases can be managed by Multidose activated charcoal and supportive care with IV fluids and symptomatic treatment. Some patients require respiratory support, atropine and pacing for symptomatic bradycardia. Insulin-dextrose is the most effective method of treating hyperkalemia. Calcium chloride is contraindicated in this instance. Specific management is digoxin specific Fab fragments. As emergency physicians may encounter these cases, they should have sound knowledge about symptoms and management. Oleander poisoning should be considered in the differential for any young patient presenting with bradycardia.