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Indian Pediatrics Mar 2024The three pathophysiologic contributors to septic shock include varying combinations of hypovolemia (relative > absolute), decreased vascular tone or vasoplegia, and...
The three pathophysiologic contributors to septic shock include varying combinations of hypovolemia (relative > absolute), decreased vascular tone or vasoplegia, and myocardial dysfunction. The three pillars of hemodynamic support include fluid boluses, vasopressors with or without inotrope infusions. The three end-points of hemodynamic resuscitation include an adequate cardiac output (CO), adequate mean arterial pressure (MAP) and diastolic blood pressure (DBP) for organ perfusion, and avoiding congestion (worse filling) parameters. Only 33-50% of septic patients show post-fluid bolus CO improvements; this may be sustained in ≥10% on account of sepsis-mediated glycocalyx injury. A pragmatic approach is to administer a small bolus (10 mL/kg over 20-30 min) and judge the response based on clinical perfusion markers, pressure elements, and congestive features. Vasoplegia marked by low DBP is a major contributor to hypotension in septic shock. Hence, a strategy of restricted fluid bolus with early low-dose norepinephrine (NE) (0.05-0.1 µg/kg/min) can be helpful. NE may also be useful in septic myocardial dysfunction (SMD) as an initial agent to maintain adequate coronary perfusion and DBP while minimizing tachycardia and providing inotropy. Severe SMD may benefit from additional inotropy (epinephrine/dobutamine). Except vasopressin, most vasoactive drugs may safely be administered via a peripheral route. The lowest MAP (5th centile for age) may be an acceptable target, provided end-organ perfusion is satisfactory. A clinical individualized approach combining the history, serial physical examination, laboratory analyses, available monitoring tools, and repeated assessment to individualize circulatory support may to lead to better outcomes than one-size-fits-all algorithms.
Topics: Humans; Child; Shock, Septic; Vasoplegia; Sepsis; Norepinephrine; Hemodynamics; Hypotension
PubMed: 38217271
DOI: No ID Found -
Cureus Dec 2023Takotsubo cardiomyopathy (TCM) is characterized by severe left ventricular dysfunction. It presents as an acute coronary syndrome; however, the difference lies in the...
Takotsubo cardiomyopathy (TCM) is characterized by severe left ventricular dysfunction. It presents as an acute coronary syndrome; however, the difference lies in the lack of coronary artery obstruction during a coronary angiogram. The left ventricular dysfunction extends beyond the area supplied with concordant coronary arteries. We describe a case of a 41-year-old female evaluated for acute coronary syndrome, later diagnosed with a unique reverse subtype of TCM.
PubMed: 38213359
DOI: 10.7759/cureus.50390 -
American Journal of Cardiovascular... 2023Takotsubo syndrome is comparable to microvascular acute coronary syndrome. It may partly share the same pathophysiology debated during scorpion envenomation (SE), with... (Review)
Review
BACKGROUND
Takotsubo syndrome is comparable to microvascular acute coronary syndrome. It may partly share the same pathophysiology debated during scorpion envenomation (SE), with an adrenergic storm, without myocardial infarction due to the absence of coronary artery stenosis. Takotsubo cardiomyopathy can help to better understand the pathophysiology of cardiac involvement during scorpion envenomation. However, Takotsubo syndrome seems to be underestimated in the literature in patients suffering from cardiac failure following SE.
METHODS
In this review, we aimed to detail all described cases, the mechanism, and outcomes of scorpion envenomation complicated by Takotsubo cardiomyopathy. We used the PubMed database by using the following keywords in MeSH research: scorpion envenomation, Takotsubo cardiomyopathy, and Takotsubo syndrome.
RESULTS
The literature analysis showed the existence of only four cases of confirmed Takotsubo cardiomyopathy following severe SE. All four patients developed a transient reversible left ventricular systolic dysfunction in the absence of coronary artery disease, following a positive history of scorpion envenomation. A cardiac MRI was performed in all cases, showing a ballooning in the left ventricle associated with a left ventricular ejection fraction in all cases. All patients were improved under symptomatic treatment, and complete recovery of the wall motion was observed.
CONCLUSION
Takotsubo syndrome, although not often reported in the literature in severe SE, can represent an effective hypothesis explaining the pathophysiology of cardiac involvement during SE. In severe scorpion envenomation, multiple mechanisms exist and can explain the development of Takotsubo syndrome. Its management is based on oxygen, with invasive or non-invasive ventilator support in patients with respiratory failure and/or cardiogenic shock. Beta-blockers, mineralocorticoid receptor antagonists, and diuretics are usually used in Takotsubo syndrome. However, in severe scorpion envenomation, all reported cases of Takotsubo cardiomyopathy are associated with cardiogenic shock and acute pulmonary edema. As a consequence, we advise the use of Dobutamine since it has already been confirmed that cardiac dysfunction following scorpion envenomation improves well and safely under Dobutamine infusion.
PubMed: 38205067
DOI: No ID Found -
Hellenic Journal of Cardiology : HJC =... Jan 2024The diagnostic value of limited myocardial ischemia in DSE is not well known.
BACKGROUND
The diagnostic value of limited myocardial ischemia in DSE is not well known.
OBJECTIVES
We investigated whether myocardial ischemia during dobutamine stress echocardiography (DSE) in 1 apical segment of any of the ventricular walls of the left ventricle relates to the anatomical and functional stenosis of the suppling coronary artery.
METHODS
Our observational, prospective study enrolled 212 patients, symptomatic or asymptomatic, with newly diagnosed limited myocardial ischemia on DSE. Almost 25% of them had already known CAD, while the rest were divided into low-risk and high-risk groups, integrating 1-2 and ≥3 classical cardiovascular risk factors, respectively. After DSE, all patients underwent invasive coronary angiography (ICA) and were followed up for one year. In coronary arteries distributing ischemic area, the calculated stenosis ≥50% and FFR<0.8 were considered anatomically and functionally significant, respectively. In the latter cases, the patients underwent coronary revascularization.
RESULTS
Significant anatomical and functional stenosis of the supplying coronary artery was common among patients with already known CAD (62.5% and 44.5%, respectively) or those without CAD but a high-risk profile (60.2% and 25.6%, respectively). In logistic regression analysis, CAD revascularization was independently determined by an already known CAD, diabetes mellitus, and high-risk profile. During follow-up, 24 patients experienced ACS or new angina episodes, which were associated with diabetes and smoking in univariate analysis.
CONCLUSION
Limited myocardial ischemia may implicate significant anatomical and functional coronary stenosis among individuals with a history of CAD or those without known CAD but a high-risk profile. The prognostic value of our findings requires further investigation.
PubMed: 38182003
DOI: 10.1016/j.hjc.2023.12.007 -
International Journal of Cardiology.... Dec 2023Epicardial adipose tissue (EAT) accumulation has been associated with inflammation, atherosclerosis and microvascular dysfunction. Whether increased EAT volume is...
BACKGROUND
Epicardial adipose tissue (EAT) accumulation has been associated with inflammation, atherosclerosis and microvascular dysfunction. Whether increased EAT volume is associated with coronary plaque vulnerability and demand myocardial ischemia in patients with non-obstructive coronary artery disease (CAD) is less explored.
METHODS
In 125 patients (median age 63[58, 69] years and 58% women) with chest pain and non-obstructive CAD, EAT volume was quantified on non-contrast cardiac CT images. EAT volume in the highest tertile (>125 ml) was defined as high EAT volume. Total coronary plaque volume and plaque vulnerability were quantified by coronary CT angiography (CCTA). Demand myocardial ischemia was detected by contrast dobutamine stress echocardiography.
RESULTS
High EAT volume was more common in men and associated with higher BMI, hypertension, increased left ventricular mass index (LVMi), C-reactive protein (CRP) and positive remodelling (all p < 0.05). There was no difference in age, coronary calcium score, total and non-calcified plaque volume or presence of demand myocardial ischemia between groups (all p ≥ 0.34). In a multivariable model, obesity (p = 0.006), hypertension (p = 0.007) and LVMi (p = 0.016) were independently associated with high EAT volume. Including plaque vulnerability in an alternative model, positive remodelling (p = 0.038) was independently associated with high EAT volume.
CONCLUSION
In non-obstructive CAD, high EAT volume was associated with cardiometabolic risk factors, inflammation and plaque vulnerability, while there was no association with demand myocardial ischemia or coronary plaque volume. Following our results, the role of EAT volume as a biomarker in non-obstructive CAD remains unclear.
PubMed: 38173787
DOI: 10.1016/j.ijcha.2023.101240 -
Cardiovascular Diagnosis and Therapy Dec 2023Prior work demonstrates patients with positive (+) electrocardiogram (ECG) but negative (-) echocardiogram wall motion abnormalities (WMAs) on dobutamine stress...
Association of abnormal electrocardiography response on dobutamine stress echocardiogram with longer-term major adverse cardiovascular events in women with symptoms of ischemic heart disease.
BACKGROUND
Prior work demonstrates patients with positive (+) electrocardiogram (ECG) but negative (-) echocardiogram wall motion abnormalities (WMAs) on dobutamine stress echocardiography (DSE) testing have an elevated of major adverse cardiovascular events (MACEs). In this study, we aimed to evaluate the long-term prognosis of women with suspected ischemia with no obstructive coronary artery (INOCA) disease by utilizing core lab read DSE, specifically focusing on those with + ECG findings.
METHODS
Among women with signs and symptoms of myocardial ischemia undergoing clinically indicated coronary angiography enrolled in the Women's Ischemia Syndrome Evaluation (WISE) [1997-2001], a prospective cohort study, 99 underwent standardized DSE by site design. Women with positive DSE (n=17), defined as an increase in score based on wall motion scoring index were excluded except for akinetic to dyskinetic (n=10), providing 82 patients in this analysis. ECG was assessed by core laboratory and (+) ECG was defined as >1 mm ST change. Non-obstructive coronary artery disease (CAD) was assessed by core laboratory quantitative coronary angiography and defined as <50% epicardial stenosis. All-cause death follow-up was an average of 8 years, while adjudicated MACE [all-cause mortality, nonfatal myocardial infarction (MI), nonfatal stroke, heart failure hospitalization] was an average of 5.5 years. Comparisons among subject groups [i.e., (+) ECG and (-) ECG] were made using chi-square or Fisher's exact tests for categorical variables and -test or Wilcoxon rank-sum test for continuous variables.
RESULTS
Demographic profile included a mean age 59±10 years; 55% had hypertension (HTN), 29% diabetes mellitus (DM), and 72% non-obstructive CAD. Overall, 9/82 women (11%) had (+) ECG in the absence of WMAs. There were significant differences in family history of CAD (P=0.009) and vasodilator (P=0.042) use between the (+) ECG and (-) ECG groups, but otherwise had no significant demographic or clinical differences. At longer-term follow up, patients with (+) ECG had higher risk of MACE [unadjusted hazard ratio (HR): 4.91, 95% confidence interval (CI): 1.83, 13.19, P=0.002].
CONCLUSIONS
Abnormal stress ECG findings on dobutamine stress testing with a negative DSE should be viewed as an indicator of longer-term risk in women with signs and symptoms of ischemia.
PubMed: 38162097
DOI: 10.21037/cdt-23-296 -
Journal of Clinical Medicine Dec 2023In head and neck reconstructive surgery, postoperative complications are a well-known concern.
The Role of Intraoperative and Early Postoperative Blood Pressure Variations, Fluid Balance and Inotropics in Fibula Free Flap Head and Neck Reconstruction: A Retrospective Analysis.
BACKGROUND
In head and neck reconstructive surgery, postoperative complications are a well-known concern.
METHODS
We examined 46 patients who underwent ablative surgery and received fibula free flap reconstruction. The main focus was to assess the influence of intraoperative blood pressure fluctuations and the administration of inotropic drugs on complications, either related to the flap or systemic, serving as the primary endpoint.
RESULTS
Utilizing logistic regression models, we identified that intraoperative mean arterial blood pressure (MAP) drops did not correlate with the occurrence of either flap-related complications (MAP < 70, = 0.79; MAP < 65, = 0.865; MAP < 60, = 0.803; MAP < 55, = 0.937) or systemic medical complications (MAP < 70, = 0.559; MAP < 65, = 0.396; MAP < 60, = 0.211; MAP < 55, = 0.936). The occurrence of flap-related complications significantly increased if a higher dosage of dobutamine was administered (median 27.5 (IQR 0-47.5) vs. 62 (38-109) mg, = 0.019) but not if norepinephrine was administered ( = 0.493). This correlation was especially noticeable given the uptick in complications associated with fluid overload (3692 (3101-4388) vs. 4859 (3555-6216) mL, = 0.026).
CONCLUSION
Intraoperative and immediate postoperative blood pressure fluctuations are common but are not directly associated with flap-related complications; however, dobutamine application as well as fluid overload may impact flap-specific complications.
PubMed: 38137822
DOI: 10.3390/jcm12247753 -
Medicine Dec 2023Coronary artery spasms may result from supply-demand mismatch due to hypotension. Norepinephrine is more effective in ameliorating antipsychotic-induced refractory... (Review)
Review
RATIONALE
Coronary artery spasms may result from supply-demand mismatch due to hypotension. Norepinephrine is more effective in ameliorating antipsychotic-induced refractory hypotension.
PATIENT CONCERNS
Postoperative difficult-to-correct hypoperfusion occurs in patients with comorbid depression and coronary spasm; the use of norepinephrine and epinephrine for rapidly raising blood pressure needs to be considered.
DIAGNOSES
Electrocardiogram is an auxiliary tool and Digital Substraction Angiography is the gold standard for the diagnosis.
INTERVENTIONS
Surgery and correct choice of raising blood pressure are the main treatment methods.
OUTCOMES
Hypotension induced by the use of antipsychotics after angiography is difficult to correct with dobutamine, and the above scenario is relatively rare in the clinic, where norepinephrine could be a potential therapeutic option.
LESSONS
Based on the lessons learnt from this case, caution must be exercised when dealing with patients on multiple antipsychotics during the perioperative period, while pressor-boosting medications should not be limited to conventional drugs such as dopamine. Norepinephrine may be more effective in dealing with difficult-to-correct hypoperfusion.
Topics: Humans; Coronary Vasospasm; Antipsychotic Agents; Hypotension; Norepinephrine; Epinephrine
PubMed: 38115312
DOI: 10.1097/MD.0000000000036400 -
Frontiers in Cardiovascular Medicine 2023Patients with heart failure (HF) with reduced left ventricular (LV) ejection fraction (EF) have a heterogeneous prognosis, and assessment of coronary physiology with...
BACKGROUND AND AIMS
Patients with heart failure (HF) with reduced left ventricular (LV) ejection fraction (EF) have a heterogeneous prognosis, and assessment of coronary physiology with coronary flow velocity (CFV) and coronary flow velocity reserve (CFVR) may complement established predictors based on wall motion and EF.
METHODS AND RESULTS
In a prospective multicenter study design, we enrolled 1,408 HF patients (age 66 ± 12 years, 1,035 men), with EF <50%, 743 (53%) with coronary artery disease, and 665 (47%) with normal coronary arteries. Recruitment (years 2004-2022) involved 8 accredited laboratories, with inter-observer variability <10% for CFV measurement. Baseline CFV (abnormal value >31 cm/s) was obtained by pulsed-wave Doppler in mid-distal LAD. CFVR (abnormal value ≤2.0) was assessed with exercise ( = 99), dobutamine ( = 100), and vasodilator stress (dipyridamole in 1,149, adenosine in 60). Inducible myocardial ischemia was identified with wall motion score index (WMSI) stress > rest (cut-off Δ ≥ 0.12). LV contractile reserve (CR) was identified with WMSI stress < rest (cutoff Δ ≥ 0.25). Test response ranged from score 0 (EF > 30%, CFV ≥ 32 cm/s, CFVR > 2.0, LVCR present, ischemia absent) to score 5 (all steps abnormal). All-cause death was the only endpoint. Results. During a median follow-up of 990 days, 253 patients died. Independent predictors of death were EF (HR: 0.956, 95% CI: 0.943-0.968, < 0.0001), CFV (HR: 2.407, 95% CI: 1.871-3.096, < 0.001), CFVR (HR: 3.908, 95% CI: 2.903-5.260, < 0.001), stress-induced ischemia (HR: 2.223, 95% CI: 1.642-3.009, < 0.001), and LVCR (HR: 0.524, 95% CI: 0.324-.647, = 0.008). The annual mortality rate was lowest (1.2%) in patients with a score of 0 (= 61) and highest (31.9%) in patients with a score of 5 ( = 15, < 0.001).
CONCLUSION
High resting CFV is associated with worse survival in ischemic and nonischemic HF with reduced EF. The value is independent and additive to resting EF, CFVR, LVCR, and inducible ischemia.
PubMed: 38075970
DOI: 10.3389/fcvm.2023.1290366 -
Journal of Clinical Medicine Nov 2023Veno-arterial extracorporeal membrane oxygenation (vaECMO) removal reflects a critical moment and factors of adverse outcomes are incompletely understood. Thus, we...
BACKGROUND
Veno-arterial extracorporeal membrane oxygenation (vaECMO) removal reflects a critical moment and factors of adverse outcomes are incompletely understood. Thus, we studied various patient-related factors during vaECMO removal to determine their association with outcomes.
METHODS
A total of 58 patients from a university hospital were included retrospectively. Demographic, clinical, and echocardiographic parameters were recorded while under vaECMO support, as well as the need for inotropic and vasoactive-inotropic scores (VIS). Successful weaning was defined as 28-day survival without reinitiation of vaECMO.
RESULTS
Patient age differed significantly between patients with a successful and a failed vaECMO weaning (54 ± 14 vs. 62 ± 12 years, = 0.029). In univariable logistic regression, age (OR 0.952 (0.909-0.997), = 0.038), the necessities for inotropic agents at the time of echocardiography (OR 0.333 (0.113-0.981), = 0.046), and vaECMO removal (OR 0.266 (0.081-0.877), = 0.030) as well as the dobutamine dose during removal (OR 0.649 (0.473-0.890), = 0.007), were significantly associated with a successful weaning from vaECMO. Age (HR 1.048 (1.006-1.091), = 0.024) and the VIS (HR 1.030 (1.004-1.056), = 0.025) at the time of vaECMO removal were independently associated with survival in bivariable Cox regression. In Kaplan-Meier analysis, a VIS of >5.1 at vaECMO removal was associated with impaired survival (log-rank = 0.025).
CONCLUSIONS
In this cohort, age and the extent of vasoactive-inotropic agents were associated with adverse outcomes following vaECMO, whereas echocardiographic biventricular function during vaECMO support was not.
PubMed: 38068459
DOI: 10.3390/jcm12237406