Webmedcentral - Cardiology ArticlesThe Cardiology articles published by Webmedcentral
http://www.webmedcentral.com
2024-03-29T06:09:25+01:00webmedcentral logo
http://www.webmedcentral.com/
http://www.webmedcentral.com/images/Header_Logo.giftext/html2013-08-13T08:10:41+01:00http://www.webmedcentral.com/Prof. Francisco R Breijo-MarquezA Broken Heart Syndrome in an Electrocardiogram with a short PR-Interval
http://www.webmedcentral.com/article_view/4364
Takotsubo disease is being widely studied in recent times and different terms have been used to describe the disorder. This form of cardiomyopathy is of a non-ischemic nature characterized by sudden temporary weakening of the myocardium (1, 2). Such sudden weakness looks be triggered by physical or emotional stress (3), as in the case of the death of a loved one. For this reason the disease is often also known as “broken heart syndrome”. It has also been reported in cases of partial drowning.
The typical presentation of Takotsubo cardiomyopathy comprises sudden-onset congestive heart failure and/ or chest pain associated with electrocardiographic abnormalities suggestive of acute myocardial ischemia of the anterior wall (4). Throughout the course of the evaluation of the patient, we often observe a bulging of the left ventricular apex with basal hypercontractility of the left ventricle (as established by echocardiography). This is the main characteristic of Takotsubo disease, which means “octopus trap” in Japanese (the first case of the disorder being reported in Japan).
The underlying cause appears to involve high levels of circulating catecholamines (mainly adrenaline / epinephrine) (1,3,4), but this aspect has not been studied in depth. Further studies are therefore needed to confirm this origin of the disease.
Another very important feature in Takotsubo disease is that the blood levels of the typical cardiac markers of myocardial infarction are normal or only very discreetly elevated.
The evaluation of patients with Takotsubo cardiomyopathy typically includes coronary angiography, which may not reveal significant obstructions capable of causing left ventricular dysfunction.
Among survivors of the initial presentation of the disease, left ventricular function is seen to improve within two months (4).
Takotsubo cardiomyopathy looks be more common in postmenopausal women, and patients usually present a recent history of severe physical or emotional stress (1-4).
A Short PR-Interval (5, 6) may be associated with an otherwise normal electrocardiogram or an untold number of bizarre electrocardiographic abnormalities. Clinically, the individual may be asymptomatic or experience a variety of complex arrhythmias, which may be disabling but rarely cause sudden death. The PR-interval starts from the beginning of the P-wave (sinoatrial node depolarization), and includes the whole P-wave, i.e., the full duration of atrial depolarization. This is followed by a flat segment until depolarization reaches the atrioventricular (AV) node, creating an electrical interlude. The AV node delays conduction of the electrical impulse long enough for the ventricles to be filled by atrial contraction before the ventricles themselves contract.
The PR-interval ends as ventricular depolarization begins (the start of the QRS complex). Thus, the PR-interval represents the time it takes for the atria to depolarize and transmit electrical communication to the ventricles. It is measured from the beginning of the P-wave to the beginning of the QRS complex. The normal PR-interval measures 0.12 to 0.20 seconds in length. A short AV conduction time, whether associated to a normal or abnormal QRS complex, is correlated to an increased incidence of paroxysmal rapid heart beats. A considerable number of patients have a short PR-interval, a normal QRS complex and bouts of tachycardia.
Evidence is presented suggesting the action of endocrine and autonomic nervous system factors in the origin of both the short PR-interval and Takotsubo disease.
Nevertheless, the coexistence between Takotsubo disease and a short PR-interval has been little studied to date (7).
In 1952, Lown, Ganong and Levine (L-G-L) described an abnormal shortening of the PR-interval regarded as a pre-excitation syndrome, a case of true accelerated atrioventricular conduction. L-G-L syndrome may affect about 1/50,000 persons. In the absence of significant structural heart disease, the mortality rate appears to be low, though fatalities are not uncommon. Patients may experience an acute episode of tachycardia or a history of symptoms suggestive of paroxysmal tachycardia. Sudden death is caused by the presence of ventricular fibrillation; it not previously diagnosed and not has been treated correctly.text/html2014-03-11T12:41:20+01:00http://www.webmedcentral.com/Prof. Francisco R Breijo-MarquezAccelerated atrioventricular stimulation with an early and shortened ventricular repolarization in the same individual
http://www.webmedcentral.com/article_view/4589
LEARNING OBJECTIVE.
Raise awareness all cardiologists that this kind of problems in the heart's electrical system exist and must be carefully assessed.
ABSTRACT:
We will present a clinical condition characterized by the presence of a short PQ interval and a short QT interval in the same individual.
The Short PQ syndrome is characterized by a duration < 0, 12 seconds. We know its variants.
The short QT syndrome has been described recently (2000-03). We speak of short QT if its length is < 0.350 second.
Both are known individually. However, there is an electrocardiographic pattern little known until today:
A pattern with short "PQ-interval and QT-interval” in the same ECG tracing.text/html2018-03-08T07:30:57+01:00http://www.webmedcentral.com/Ms. Nadezhda HvarchanovaGender Differences in Comorbidities of Heart Failure Patients with Preserved or Reduced Left Ventricular Ejection Fraction
http://www.webmedcentral.com/article_view/5439
Introduction/AimThe aim of this study was to establish gender differences in the comorbidities of heart failure (HF) patients both with preserved (HFpEF) or reduced (HFrEF) left ventricular ejection fraction Materials and MethodsThis is a retrospective study including 535 heart failure patients hospitalized in the period January, 2010 - December, 2014 with the rate of comorbidities in both groups - HFpEF and HFrEF being examined, including diabetes, hypertension, chronic obstructive pulmonary disease (COPD), atrial fibrillation, anemia and impaired kidney function based on the estimated glomerular filtration rate (eGFR).ResultsIn this study females with HF tended to be older, more numerous and more likely than men to have comorbid impaired renal function and both genders had similar occurrence of all other comorbidities. Patients with HFpEF had hypertension more often and atrial fibrillation less often, compared to those with HFrEF. Females with HFpEF had hypertension more often and atrial fibrillation less often, compared to their counterparts with HFrEF. Males with HFpEF and HFrEF exhibited no differences in comorbidities whatsoever. Females with HFpEF and HFrEF had more impaired renal function than males and more frequently atrial fibrillation, if with HFrEF.ConclusionThere was an increasing predominance of HFpEF, older age and female gender in HF hospitalizations over time. Registries and “real-life” investigations generally report higher prevalence of comorbidities compared to clinical trials but the impact on mortality seems to be different as mortality rates and causes of death are comparable between both sexes with slightly better survival in women, in contrast to their higher burden of comorbidities.text/html2010-09-06T22:21:44+01:00http://www.webmedcentral.com/Dr. Muralikrishna GopalCircadian Variation In Acute Coronary Syndromes
http://www.webmedcentral.com/article_view/533
Background: Studies have shown that a circadian rhythm may exist in the onset of acute coronary syndromes. More studies are needed in the Indian population to confirm the existence of this circadian variation and add to the existing literature in the Indian population. Methods: Two hundred twenty consecutive patients with acute coronary syndromes, admitted to the coronary care unit were included in the study. The time of onset of symptoms was noted into six categories of four hours each. Results: The statistical analysis of the data obtained showed that acute coronary syndromes was commonest from 4am to 8 am (35%, P valueConclusions The circadian variation in the time of onset of acute coronary syndromes in an Indian population is similar to data published in the western literature, with a peak in the early morning. This variation appears to be exaggerated in the treatment naïve-hypertensive population. Further research is needed to assess the cellular and neuro-hormonal mechanisms of this circadian variation and may have implications in therapeutics.text/html2010-10-26T11:38:19+01:00http://www.webmedcentral.com/Dr. Attila MihalczEvolution Of The Paced And Non-paced Qrs Duration With Chronic Right Ventricular Pacing In Pediatric Patients With And Without Structural Heart Disease
http://www.webmedcentral.com/article_view/1076
Background: Right ventricular (RV) pacing creates artificial left ventricular (LV) dyssynchrony and thus can be used as a surrogate for left bundle branch block (LBBB). Assuming this, our aim was to assess the evolution of the QRS width in chronically paced pediatric patients with and without structural heart disease (SHD).Methods: A group of 99 pediatric patients with a previously implanted pacemaker was studied retrospectively. Forty-three patients had isolated atrioventricular block (IAVB) and the remaining 56 patients had SHD. Patients were followed up for an average of 52.83±41.42 months. QRS duration was measured in lead V5 or II on ECG recordings with paper speed of 50 or 25 mm/sec. Data on QRS width were analyzed in six age groups (group I:Results: Paced QRS duration showed progressive widening during the follow-up (group I: 109.3±23.4 ms, group VI: 155±27.9 ms, pConclusions: Chronic RV pacing in pediatric patients with or without structural HD does not cause widening of the QRS complex over 120 ms until the end of the first year of life. Paced QRS duration of 130 ms is not reached until the age of 3 to 4 years. The presence of structural HD results in a wider paced and intrinsic QRS complex.
text/html2011-03-11T22:25:18+01:00http://www.webmedcentral.com/Dr. Antonella RagusaAn Unusual Cause of Cerebral Ischemia in the Elderly: Left Atrial Myxoma
http://www.webmedcentral.com/article_view/1735
Intracardiac primary tumors are rare conditions. The 75% of them are benign, the 25% malignant and approximately 50% are myxomas in adults. About 75% of atrial myxoma arise in left atrium, while right atrial myxomas occurring only in the 15-20% of all cases as discussed elsewhere [1-3]. The symptoms are atypical and higly variable, often they may remain asymptomatic as discussed by Yuce [4]. According their size, mobility and location, myxomas may present lung congestion, syncope, sudden death due to thrombo – embolic phenomenon, while exertional dyspnea, syncope or sudden death are caused by valve obstruction, as discussed elsewhere [1, 5, 6-7]. It has been reported by Uner and Lee, that neurologic complication are associated with cardiac myxoma in the 26% to 45% of patients with cerebral embolic infarct being the most frequently event observed [8-9]. Furtheremore constitutional symptoms like fever, weight loss, arthralgias, Raynaud’s phenomenon, anaemia, hypergammaglobulinemia, elevated erythrocyte sedimentation rate are related to the production of interleukin 6 as discussed by Kanda. [10]. 5 % of patients with cardiac myxoma may moreover show the simultaneous presence of multiple genetical disorders. This clinical condition is known as “Carney Complex”. The clinical manifestation of this syndrome could present skin pigmentary abnormalities (lentigines or blue nevi), multiple cardiac myxomas at a young age, endocrine tumors, endocrine overactivity, less frequently schwannomas, or multiple myxomas involving breast, skin, oropharynx or female genital tract as discussed elsewhere[11-12]
Echocardiography is the standard diagnostic technique and the surgical removal is the recommended therapy, as is it usual curative, as discussed by Reynen [2]. text/html2011-06-10T20:02:18+01:00http://www.webmedcentral.com/Dr. Thomas F HestonRegadenoson Cardiac Stress Myocardial Perfusion Scintigraphy
http://www.webmedcentral.com/article_view/1973
Regadenoson (Lexiscan TM) is a pharmacologic cardiac stress test agent that results in coronary artery vasodilation. Healthy coronary arteries dilate, whereas arteries with extensive atherosclerosis or coronary spasm do not. Patient with microvascular disease also have decreased vascular dilation in response to regadenoson. The result is an alteration in coronary blood flow, with a relative decrease in flow to vascular territories distal to diseased vessels and a relative increase in flow to vascular territories served by healthy vessels. This alteration in blood flow is detected on a molecular level by nuclear myocardial perfusion imaging. Patients with extensive disease may have normal myocardial perfusion at rest because the alteration in blood flow is not pronounced. When there is a significant alteration in myocardial blood flow during stress, but normal blood flow at rest, the patient is demonstrating inducible myocardial ischemia, and is at an increased risk of adverse cardiac events.Patients with normal or near normal perfusion during cardiac stress do best with risk reduction and medical therapy, whereas patients with evidence of inducible ischemia affecting about 10% or more of the left ventricle have a mortality benefit from revascularization. This was first demonstrated by Hachamovitch et al (Circulation. 2003 Jun 17;107(23):2900-7) and subsequently supported by the COURAGE Trial (N Engl J Med. 2007 Apr 12;356(15):1503-16) and by additional work by Hachamovitch et al (Eur Heart J. 2011 Apr;32(8):1012-24).Hachamovitch's reseach, published by Circulation in 2003, includes an important figure demonstrating the usefulness of myocardial perfusion scintigraphy in guiding patient therapy. Figure 4 in the manuscript demonstrates that when the % Total Myocardium Ischemic is below about 10%, medical therapy alone is associated with a lower log hazard ratio (greater survival). When the % Total Myocardium Ischemic is above about 10%, revascularization was associated with a survival benefit. As the percentage of ischemic myocardium increased, survival decreased.Exercise treadmill testing is the preferred method of cardiac stress when performing a stress myocardial perfusion scan, however, it is important that the patient be able to perform adequate stress in order to achieve an acceptable diagnostic accuracy. At low levels of stress, the coronary vasodilation is not stimulated enough to result in an alteration in regional coronary blood flow when diseased vessels are present.In general, adequate stress is defined as achieving 85% or more of their predicted maximum heart rate [= 0.85 * (220-age)]. Patients with atrial fibrillation or with severe deconditioning may achieve this target heart rate quickly when performing treadmill stress. In these patients, there is some controversy over what defines adequate stress. A rule of thumb is that patients should be able to exercise at least 3 minutes of a Bruce Protocol stress test and achieve 85% of their predicted maximum heart rate. Another metric used is the double product (= heart rate times systolic blood pressure), with a value of 20,000 or greater suggesting that adequate stress has occurred.Adequate stress can also be defined simply as fatigue, when the purpose of the stress test is to determine a patient's response to medical therapy. In these patients, their cardiac medications are NOT held for the test since the goal is to determine whether or not inducible ischemia occurs when the patient is on their medications.For patients unable to perform exercise stress testing, pharmacologic stress testing can be used. The three most common agents used in conjunction with myocardial perfusion imaging are dipyridamole, adenosine, and regadenoson. All act by vasodilating the coronary vessels. All require that patients refrain from caffeinated products for a minimum of 12 hours, and ideally for 24 to 48 hours.To date, research on all three agents have found that they all have a similar side-effect profile, and a similar rate of side-effects. Although there are theoretical benefits for adenosine over dipyridamole (the short half-life) and a theoretical benefit of regadenoson over adenosine (more cardioselective for adenosine receptors), these theoretical benefits have not been shown to decrease side-effects compared to the inexpensive, original agent dipyridamole.Nevertheless, there are a couple of possible benefits of regadenoson. It is administered as a single rapid bolus, whereas both adenosine and dipyridamole are infused over several minutes. This has important implications in terms of physician time and patient throughput.In addition, researchers have found that patients subjectively feel better after regadenoson stress compared to after adenosine stress (Iskandrian et al, J Nucl Cardiol. 2007 Sep-Oct;14(5):645-58, Cerqueira et al, JACC Cardiovasc Imaging. 2008 May;1(3):307-16). This “Tolerability Score” was determined by asking patients after stress the simple question, “how do you feel?” After regadenoson stress, 91% of patients responded that they felt comfortable or only slightly uncomfortable, compared to 82% of patients undergoing adenosine stress. To my knowledge, there are no studies that look at patient responses to this question after dipyridamole stress testing.Overall, the rate of any adverse cardiac event after regadenoson is no different than after adenosine, both occurring at a rate of 79% in Iskandrian's original research. Furthermore, when only looking at severe cardiac events, there also is no difference between adenosine and regadenoson (7% vs 5%, p=0.32). Only when researchers selectively looked at a combined score of just 3 side-effects (flushing, chest pain, or dyspnea) was there a statistically significant advantage to regadenoson over adenosine. However, it was not said why these 3 symptoms were selected out, and other symptoms such as headache, nausea, angina pectoris, or chest discomfort were not included. This violates basic statistical principles and could be though of as data mining.It is important to not that the research to date has been heavily supported by the manufacturer of regadenoson, with several authors having financial ties to the company. This may explain in part why a new “tolerability score” was developed, and selective symptom scores created.When only looking at severe events, to date, regadenoson has not been shown to be superior to adenosine.No direct comparisons have been made between regadenoson and dipyridamole in terms of a “Tolerability Score” or side-effect profile. We can confidently say that neither adenosine nor regadenoson have been clearly shown to be superior to dipyridamole in terms of patient safety, patient tolerability, or clinical utility. The latest Stress Protocols Guidelines from the American Society of Nuclear Cardiology states that the frequency of minor side effects is less with dipyridamole as compared to adenosine. Furthermore, the incidence of AV block with dipyridamole is less than that observed with adenosine. However, no large studies are available to compare the rates of major side effects of these three agents.What we do know is the dipyridamole is as safe as exercise stress testing. The largest study of dipyridamole was a multinational study looking at 73,806 patients (Lette et al J Nucl Cardiol. 1995 Jan-Feb;2(1):3-17). In this group of patients undergoing hospital-based dipyridamole cardiac stress myocardial perfusion imaging, there were 7 cardiac deaths, 13 nonfatal myocardial infarctions, sustained ventricular arrhythmias in 6 patients requiring cardioversion, and 9 cases of acute bronchospasm. For exercise treadmill testing, the rate of severe complications is about 5 in 10,000 with 1 of these being cardiac death and the other 4 non-fatal myocardial infarction. This is almost identical to the dipyridamole rate of 0.95 cardiac deaths per 10,000 and 3.8 non-fatal but serious side-effects per 10,000. The rate of side-effects in an outpatient population is known to be significantly less.It remains possible that regadenoson will ultimately be shown to have a lower rate of serious side effects compared to dipyridamole. However, it is also possible that the rate of side effects is higher than dipyridamole. This is a distinct possibility, given that it has been shown that adenosine has a higher rate of side effects compared to dipyridamole.What is clear is that dipyridamole is significantly less expensive than either adenosine or regadenoson, and the regadenoson research has been heavily supported by industry, which has both sponsored the research and hired several of the authors to be consultants or participate in their speakers' bureau.text/html2011-06-11T15:40:49+01:00http://www.webmedcentral.com/Dr. Deepak GuptaWhat is the Role of Telemetry in Patients with Pacemakers?
http://www.webmedcentral.com/article_view/1975
Cardiac telemetry has been used inappropriately due to the lack of evidence based guidelines for initiation and discontinuation of the telemetry [1-4]. Additionally, cardiac telemetry in itself is imperfect for monitoring the mechanical activity of the heart which is an essential monitoring parameter for patients with permanent pacemaker. The pacemakers can easily override deteriorating intrinsic rhythms and replace it with pacemaker rhythm even though the cause of loss of intrinsic rhythm may be interfering with the cardiac contractility. Even the Closed Loop Stimulation (CLS) in the pacemakers by BIOTRONIK® (Berlin, Germany) with capability to measure the intra-cardiac impedance for early detection and response to the deterioration in contractility does not overcome the shortcoming of cardiac monitoring by inpatient telemetry because the BIOTRONIK® Home Monitoring is yet not synchronized in real time to the inpatient cardiac telemetry. Therefore, pulseless electrical activity (PEA) remains a big challenge for cardiac telemetry. PEA usually deteriorates into bradycardia (slow PEA) that rapidly converts into asystole because the blood supply to the cardiac conduction system has been abruptly shut off by the absence of contractility. However, when the patient has a pacemaker, the pacemaker spikes override the slow PEA rhythm with no display of impending/ongoing asystole that can go unnoticed on remote telemetry before the patient’s physical condition is reassessed and reviewed by other means. To avert this life-threatening scenario, it seems prudent to simultaneously telemonitor cardiac contractility by other means [5] including but not limited to intra-arterial catheter (IAC) waveform, continuous echocardiography (ECHO) and pulmonary artery catheter (PAC) waveform. However, these invasive monitoring devices require patient’s continuous stay in intensive/intermediate care unit. Therefore, the most amenable solution for transferring the patients with pacemakers to floor beds is that cardiac telemetry should be integrated with continuous wireless monitoring of non-invasive photoplethysmograph and/or respiration because photoplethysmograph waveform and acoustic respiration monitoring communicate the global effect of loss of cardiac contractility. This integrated monitoring will keep the patients with permanent pacemakers safe, mobile and comfortable outside the cost-ineffective domains of the modern day intensive care units.text/html2011-11-25T18:00:44+01:00http://www.webmedcentral.com/Dr. Deepak GuptaPre-Load and After-Load: Rhythm of Life, More so in Stiff Hearts
http://www.webmedcentral.com/article_view/2507
The functioning of cardiovascular system is grossly dependent on three variables, namely Pre-Load, Contractility and After-Load. Pre-Load is majorly dependent on the venous return to heart; Contractility is the intrinsic contractile activity of the heart to deliver the returned venous blood; and After-Load is the resistance of the cardiovascular arterial system that accepts the re-circulated blood. All three determinants work in synchronized rhythmic fashion to maintain the essence of life. However, as the symptoms of heart failure especially diastolic heart dysfunction surface leading to poorly contracting and/or relaxing myocardium, this rhythm of life maintained by the Pre-Load and After-Load takes the lead to ensure the survival of patient with good quality of life. The focus of my opinion is to present that the drugs are not the only ways to maintain an adequately compensated rhythm; instead the day to day observations of the patients’ activities do provide us with the information for the non-pharmacological measures that have been ignored secondary to blinding light of the booming pharmaceuticals. The point is not to get away with the medications, but to incorporate the day to day adjustments in our activities that were so obvious in our immediate fore-sight that we have long ignored to pay attention to them.Let me start with the first obviate: why climbing up flight of stairs is more stressful than climbing down flight of stairs and this difference is not in synchrony to the documented half to one-third of the energy spent in climbing down the stairs as compared to the climbing up. People usually can climb down any number of stairs; however climbing up may be restricted to two to three flight of stairs in most of the population. This disproportionate effect can not be adequately explained just by the difference in the metabolism. However, when the rhythm of life is taken in consideration, we see the matter in a different light. Climbing up the stairs involve constant or worsening increase in the After-Load by the contracting lower extremity muscles to counter gravitational energy even though the Pre-Load is constantly trying to match and fill the contracting/relaxing heart that eventually signals to the body to give it a rest; however while climbing down the stairs no stiff leg muscles are required for favorable gravitational energy and hence the Pre-Load is not stressed out as the After-Load is in relaxed mood, and the contracting/relaxing heart can have a longer run while climbing down the stairs before it raises hands for a break. Let us move on to the second obviate: is stress an exclusive cerebral phenomenon or are we ignoring the major contributions of the cardiovascular dysregulation. We all have observed that same amount of stress (physiological or psychological) behaves differently across the population and we as physicians primarily focus on subliming the inciting agent (stressful stimulus) without focusing on the conditioning of the whole body especially cardiovascular system that is the primary exacerbator of the body’s differential response to the stressful stimulus. The focus again turns to the rhythm of Pre-Load and After-Load wherein the fluctuating Pulmonary Vasculature and Cerebral Arterial After-Loading secondary to the Stiff Arterial Systems and Poorly Relaxing Heart overshoots the psychologically anxious scenario to a vicious physiological stress cycle. And thereafter, people with poor hearts and erratic lungs explode the minimal cerebral stress or psychological event into the catastrophic torpedo of panic attacks.And finally, moving on to the final obviate for this discussion: how shavasana (a yoga position also called corpse pose wherein all body muscle tension is released to lie down flat on a surface) works (1-2) or is it myth/placebo. However, if we apply our non-biased minds to the reasoning, we will realize that the rhythm of Pre-Load and After-Load comes to our rescue once again. When the whole body muscle tension is released then the After-Load on beating heart becomes minimal and the heart that is full of passively returning blood from relaxed supine positioned patient beats with great zeal. This good functioning of the cardiovascular system promotes the healing of the stress within the body because stress is not an exclusive cerebral phenomenon. In the same context, even when the person is not in the position of shavasana, the person can focus on keeping his/her muscles relaxed so that unwanted exacerbation of After-Load can be constantly avoided. It is easier said than done but one can start with keeping his/her fists open rather closed as closed fists are only contributing to disproportionately higher increase in the Upper-Extremity’s contribution to After-Load as compared to Upper-Extremity’s contribution to Pre-Load. Additionally, the disproportionate muscle mass and hence muscular pumps of the upper extremities versus lower extremities may explain that people with eventually deteriorating stiffer hearts are able to walk on flat surfaces that increase Pre-Load from calf muscles without worsening After-Load as compared to their accentuating capacity to perform day to day hand-performed activities that primarily elevate the After-Load without improvement in the limited Pre-Load contribution from the arm muscles.In summary, the point is that anxiety is only an inciting stimulus; it is the elasticity/plasticity of the responding cardiovascular system that defines the final patho-physiological picture. And it will not be harmful to understand and realize the maintenance of a good rhythm between our Pre-Load and After-Load by maintaining good flat-surface walks even if instrumental activities of daily living or activities of daily living have suffered a blow; or by climbing down the stairs even when our cardiovascular system (CVS) wants us to climb up elevators; or by taking it easy rather than completing it fast when our room for error between the Rock of Psychological Incite and the Hard Place of Stiff CVS has been squeezed to miniscule. Because Pre-Load and After-Load is Rhythm of Life, More So in Stiff Hearts but Not Only for Them.text/html2011-12-09T18:08:30+01:00http://www.webmedcentral.com/Dr. Wael AlkhiaryPremature Myocardial Infarction: An updated Overview
http://www.webmedcentral.com/article_view/2597
Although myocardial infarction (AMI) is usually the disease of older people over 45 years of age, an increasing number of younger patients is being recorded. Additionally, AMI in very young patients aged 35 years and younger has been poorly described. Besides atherosclerotic coronary artery disease, non-atherosclerotic coronary artery diseases or hypercoagulability should be considered for young cases of myocardial infarction. The predominance of angiographic single-vessel disease and myocardial infarction with normal coronary arteries in these patients primarily suggest that premature myocardial infarction probably result from a rapid progressive event, such as thrombosis or plaque rupture, rather than a gradually evolving process, such as atherosclerosis. In the future, atherosclerotic burden, hemostatic function, characterization of stressors and inflammation will be important targets for research in this group of patients.text/html2011-12-26T09:54:50+01:00http://www.webmedcentral.com/Dr. Jiri KobrUltrasound Monitoring of Right Ventricular Haemodynamics in Children with Complications of Respiratory Syncytial Virus Infection
http://www.webmedcentral.com/article_view/2785
Background: The aim of this study was to verify the benefits of a separate evaluation of pulmonary and systemic haemodynamics for the management of treatment. For the purposes of this study, we selected the data of the time period from 2006 to 2010.Methods: A total of 53 children, average age 1.82 years (SD 1.06) were included in the study and divided according to Lung Injury Score (LIS) and Predicted Risk Index Scoring of Mortality (PRISM). Group A (n= 25) included patients with LIS?1.5 points; PRISM?20 points and group B (n= 28) patients with LIS 1.0-1.4 points; PRISM 10-19 points. A transthoracic echocardiography (TTE) combined with ultrasound cardiac output monitoring (USCOM) was used. The myocardial performance indices (MPI RV/LV), pulmonary and systemic vascular resistance (PVR; SVR), cardiac index (CI RV/LV) and other parameters were collated one hour after initiation of therapy (time-1) and after 48 hours of treatment (time-2) for statistical evaluation. All the data were compared within groups and between groups using the distribution-free Wilcoxon’s and two-way ANOVA tests.Results: A total of 232 TTE and USCOM examinations were performed. At time-1 higher median values of MPI RV (0.32, SD 0.01 vs. 0.21, SD 0.01; pConclusion: The RSV infection was complicated by the adverse change of pulmonary haemodynamics. Right ventricular afterload increased, depending on the duration of hypoventilation. Haemodynamic monitoring provides valuable real-time information to improve efficiency of therapy.text/html2012-01-09T15:48:35+01:00http://www.webmedcentral.com/Dr. Abhinav VaidyaCoronary Angiographic Findings of Nepalese Patients with Critical Coronary Artery Disease: Which Vessels and How Severe?
http://www.webmedcentral.com/article_view/2864
Background: Coronary heart disease is a rising cause of adult death in Nepal. Diagnostic and interventional facilities such as coronary angiography and angioplasty have also collaterally improved in Nepal over the last decade. This study explores the most common coronary vessels involved in the Nepalese population based on the coronary angiographic findings.Methods: This is a retrospective study of 852 Nepalese patients who underwent coronary angioplasty from early 2002 to 2010 end at Norvic International Hospital, Kathmandu.Results: Single vessel disease was most common (69.06%) followed by double vessel disease (25.84%) and triple vessel disease (5.10%). Left Anterior Descending artery was most frequently affected (56.0%) followed by Left Circumflex Artery (34.2%) and Right Common Artery (31.4%). Left Main coronary artery was found to be severely stenosed in 0.4% cases.Conclusion: The study has shown that the most Nepalese patients presented with single vessel disease with Left anterior descending as the most frequent culprit artery.text/html2012-02-17T10:04:31+01:00http://www.webmedcentral.com/Dr. Mohsin A HussainA Unique Case of Quincy Complicated by Complete Heart Block and Ventricular Tachycardia: A Case Report
http://www.webmedcentral.com/article_view/3001
Introduction: A peri – tonsilar abscess, also known as quincy, is a condition which can present as a sore throat and represents collection of pus in the peri – tonsilar space. Treatment involves drainage of the abscess and completing a course of antibiotics. We describe a novel case whereby a patient diagnosed with quincy also suffered with complete heart block and non sustained ventricular tachycardia. The rhythm disturbances observed resolved once the quincy was treated.Case presentation: We present a case of an 89 year old caucasain lady who presented to hospital and diagnosed with a peri – tonsillar abscess. She was found to be in complete heart block that degenerated in runs of non sustained ventricular tachycardia. The non sustained ventricular tachycardia was associated with haemodynamic compromise and therefore a temporary pacing wire was inserted in addition to loading with intravenous amiodarone. The ears, nose, and throat team (ENT) drained the abscess and prescribed a course of antibiotics. Following treatment of the abscess the heart rhythm problems resolved and the patient was discharged home.Conclusion: A clear temporal relationship was observed between the onset of the quincy and the rhythm disturbances. We conclude the peri – tonsillar abscess had a local effect on the vagus nerve and resulted in complete heart block which in turn degenerated into runs of non sustained ventricular tachycardia. This is a rare but important phenomenon as it can have life threatening implications.text/html2012-05-01T17:01:54+01:00http://www.webmedcentral.com/Mr. Muhammed R SiddiquiExercise Prescription in Chronic Disease
http://www.webmedcentral.com/article_view/3187
Introduction: Heart failure (HF) is a complex clinical syndrome that is growing as a public health problem with over 1 in 7 of those over the age of 85 affected. Despite improvements in prognosis, the mortality rate remains high. Exercise training (ET) has been reported to be beneficial in patients with heart failure as it improves exercise tolerance and quality of life. The aim of this study is to see if ET is safe and if it significantly improves exercise tolerance, mortality and quality of life (QoL) in patients with heart failure.Methods: Online databases such as Medline (Ovid), PubMed and NHS Evidence were searched for any available literature on exercise training in heart failure patients. Four recent articles were chosen to be critically appraised in order to address the aim.Results: All four articles found exercise training to be safe and of some benefit for HF patients. Two studies found peak oxygen uptake (VO2 max) and 6-minute walking test (6MWT) to significantly improve with exercise. An additional study found a non-significant rise. Three of the studies found exercise to significant improve QoL.ET is beneficial for patients with HF as it is safe and would improve QoL. It may also improve their VO2 max and 6MWT to some extent.Conclusion: Exercise training may be beneficial to people with heart failure. Motivation and targets with careful intervention from community nurses may help to sustain this regimen.text/html2012-11-15T17:58:06+01:00http://www.webmedcentral.com/Dr. Branimir KanazirevSevere Hypothyroidism, Coronary Artery Disease on CT Coronary Angiography and Hypoperfusion on Contrast Echocardiography
http://www.webmedcentral.com/article_view/3825
The association between overt hypothyroidism (HT) and coronary heart disease is well known. Even subclinical hypothyroidism independently increases the relative risk of coronary artery disease and myocardial infarction and reduces coronary flow reserve. Methods and results A patient with severe HP and typical angina on exersion is presented having multiple epicardial coronary artery disease on CT-assisted coronary arteriography and decreased and heterogeneous myocardial perfusion on contrast echocardiography secondary to both macro and microvascular coronary artery disease Conclusions: Hypothyroidism is an important clinical situation and a risk factor to be considered for coronary artery involvement.text/html2012-11-29T13:16:35+01:00http://www.webmedcentral.com/Dr. Branimir KanazirevNoninvasive Evaluation of Left Ventricular Function in Patients with Hyper and Hypothyroidism
http://www.webmedcentral.com/article_view/3854
Purpose: To evaluate left ventricular function prospectively and comparatively to healthy controls and prospectively short term on standard treatment in patients with thyroid dysfunction function.
Material and methods: We investigated 39 patients with hyperthyroidism, 24 patients with hypothyroidism and 40 controls by echocardiography and systolic time intervals (STI) at beginning of treatment and six weeks later after initiation of treatment. Heart rate (HR), pre-ejection period (PEP) and its corrected value PEPc, ejection time (ET) and its corrected value (ETc) and PEP/ET ratio were studied. End-diastolic, end-systolic dimensions (EDD, ESD), shortening fraction (SF), mean velocity of circumferential fiber shortening (MVCFS), systemic vascular resistance (SVR) and left ventricular mass index (LVMi) were examined.
Results: STI in hyperthyroidism were significant different: HR was increased, ET, ETc, PEP, PEPc and PEP/ET was decreased. CI was greater, MVCFS was greater and SF was higher, SVR was decreased and LVMi was greater. In follow-up treatment significant recovery in HR, PEP, ET and ETc and MVCFS was found . STI in hypothyroid patients were significant changed: PEP and PEP/ET were increased . CI was lower and SVR was higher, MVCFS was decreased and LVMi was greater, SF and ESD were changed too. When on standard hormone replacement treatment for 6 weeks no changes in indices studied were found. High correlations were seen when plotting thyroxin hormone levels against MVCFS and between MVCFS and SVR.text/html2012-12-10T13:56:45+01:00http://www.webmedcentral.com/Dr. Namrata Chhabra\"Should Hyperhomocysteinemia be ignored?\" A case control prospective study to assess the magnitude of risk associated with hyperhomocysteinemia in chronic stable angina and the implications of Folic acid, B6 and B12 therapy.
http://www.webmedcentral.com/article_view/3879
Background: Results from prospective studies of serum homocysteine levels and ischemic heart disease (IHD) are inconclusive.
Objective: The objective of the present study was to determine the magnitude of risk associated with increased plasma homocysteine levels in the absence of other conventional risk factors in patients of chronic stable angina and to determine the extent of its reduction by folic acid, pyridoxine (B6) and B12 therapy.
Research Design: The study included 50 subjects of chronic stable angina with equal number of age and sex matched normal healthy individuals. The total plasma homocysteine, lipid profile, blood urea and serum creatinine levels were estimated in both the study groups.
Results and Interpretations: The mean plasma homocysteine concentration was higher in patients as compared to the control subjects and the difference was highly significant (p0.01). A significant reduction in plasma homocysteine concentration (p0.01).
Conclusion: Moderately high plasma homocysteine concentration is an independent but modifiable risk factor in the pathogenesis of coronary artery disease. Homocysteine can be lowered safely and effectively with folic acid and B-vitamin supplementation. The potential benefit of lowering homocysteine can have great implications for the primary and secondary prevention of ischemic heart disease.
Key Words: Homocysteine, Folic acid, Pyridoxine, Chronic stable angina, Cholesterol, Triglycerides, Very low density lipoprotein (VLDL), Low density Lipoprotein (LDL), High density lipoprotein (HDL)text/html2013-01-15T18:37:13+01:00http://www.webmedcentral.com/Dr. Gentian VyshkaClinical Features of a Case with Syndrome X
http://www.webmedcentral.com/article_view/3948
A female patient aged 52 years old showed up in our clinics complaining for restrosternal chest pain, palpitations and profuse sweating. Her complaints started several days prior to the medical visit, and such problems persisted even during rest, but aggravated during physical effort.
The patient referred an episode of atrial fibrillation three years before, which obliged her to perform an emergent hospitalization. At that period the episode of atrial fibrillation was converted through oral amiodarone therapy; thereafter she was under continuous oral therapy with aspirin 100 milligrams daily and bisoprolol 5 milligrams daily. No drug adverse effects were reported and no allergies as well; she did not presented any other major cardiac risk factor (her history was negative for hypertension, diabetes, hyperlipidemia). The patient was not a smoker and no genetic history for ischemic cardiac disease was reported. The only major medical problem referred was a hysterectomy performed ten years before the present episode.
Upon admission the patient had a body temperature of 36.8 Celsius degrees; normally coloured skin and mucosal surfaces, fully alert and active. A systolic click was auscultated; no pericardial fremissement was present, heart rate was 68 beats per minute, arterial pressure values were 110 and 70 millimetres Hg. Vesicular respiration was auscultated in all pulmonary fields. Abdominal region was palpable and no enlargement of internal viscera was seen. Kidneys resulted clinically normal and lower extremities presented no dependent oedemas; peripheral pulses were fully palpable. No bruits were auscultated over carotid arteries bilaterally and jugular veins were within normality.
Laboratory data resulted as well without significant changes from normal ranges. Negative T waves were registered on the electrocardiography in the derivations II, III and aVF.
Based upon the above mentioned clinical data the treating clinician made a differential diagnosis in between the (a) mitral valve prolapse; (b) unstable angina and (c) syndrome X
Mitral valve prolapse is one of the most common cardiac valve anomalies; previously an incidence of 5-10% in the population was referred [1]. However, after more precise and detailed criteria were elaborated, a smaller incidence of the mitral valve prolapse in the population was referred; such an incidence was rather of 2.4% [2, 3]. The mitral valve prolapse seems twice more frequent in males rather than in females.
In the present case, mitral valve prolapse was excluded after normal echography data were collected.
A stress test was thereafter registered (Figure 1).
The stress test resulted positive for coronary artery disease, with effort angina due to the depressions of S-T segment registered in the V5-V6 derivations; such depressions peaked to 1-2 millimetres. Abnormal blood pressure responding was as well registered during effort, with hypotension at the maximum of effort. No rhythm abnormalities, no conduction disorders was seen, with an overall good exercising ability.
Under these circumstances, the diagnosis was still pending between an unstable angina and syndrome X.
Unstable angina is defined as chest pain characterized through a decrease in the coronary blood flow, due to rupture of an atherosclerotic plaque, causing thereafter a partial thrombotic obstruction or embolism [4]. Such a picture should be accompanied from at least one the following:
Initiation during rest or minimal physical effort and lasting more than twenty minutes (when no nitrates are administered);
The pain has important consistence, since several days (during a single month);
The pain has an aggravating nature, i.e. it is increasing in intensity, or the painful periods are longer and more frequent than previously [1, 5].
Half of the patients with unstable angina, especially those suffering from prolonged chest pain during rest, will at the end present myocardial necrosis, whose presence is proved from an increasing of cardiac enzymes plasmatic levels, together with troponin T, I and CK-MB. Under these circumstances the diagnosis of a myocardial infarction without ST elevation is warranted.
Syndrome X is defined as an anginal pain with normal coronarography findings; such a syndrome is an important clinical entity that has to be differentiated from an ischemic heart disease due to coronary atherosclerosis. The prognosis of the syndrome X is as a rule excellent [6, 7]. Such a prognosis is obviously different in patients with angina due to coronary atherosclerosis. Patients with anginal pain and normal coronarography compose 10-20% of all patients that undergo such a diagnostic procedure, due to clinical suspicion for ischemic heart disease. The causes of this syndrome are supposed to be:
Micro vascular dysfunction or coronary spasm, leading to myocardial ischemia [8, 9];
Abnormal pain perception in patients with increased sympathetic tone.
Our patient thereafter performed a coronarography (Figure 2).
No significant coronary arteries stenosis was registered in the examination described above. Due to these findings, our patient was diagnosed with the syndrome X.text/html2013-01-29T18:15:48+01:00http://www.webmedcentral.com/Dr. Digvijay SinghElectrocardiographic Studies During Endotoxic Shock and after Flunixin Meglumine, ketanov Infusion Singly and in Combination in Male Buffalo Calves
http://www.webmedcentral.com/article_view/3975
15 apparently healthy buffalo calves were divided into 3 groups of 5 animal each. Each group was in fused E.coli endotoxin @ 5 µg/kg BW/hour for 3 hours and subsequently group 1 was intravenously Fusixin meglumine @ 1.1 mg/kg BWwhile group 2 was given intravenous infustion of Ketanov @ 1.12mg/kg BW and in group 3 a combination of there two NSAIDs was given to investigate effect of the NSAIDs alone or in combination. A decrease in ‘T’wave, its revtrsal and 2nd degree A-V conduction block was observed during infusion of endotoxin which could not be removed after I/V infusion of Flunixin meglumine or Ketanov alone or in combination. text/html2013-02-25T13:57:24+01:00http://www.webmedcentral.com/Dr. Branimir KanazirevSevere Hypothyroidism, Ccoronary Artery Disease on CT Coronary Angiography and Hypoperfusion on Contrast Echocardiography
http://www.webmedcentral.com/article_view/3858
Background: The association between overt hypothyroidism (HT) and coronary heart disease is well known. Even subclinical hypothyroidism independently increases the relative risk of coronary artery disease and myocardial infarction and reduces coronary flow reserve.Methods and results: A patient with severe HP and typical angina on exersion is presented having multiple epicardial coronary artery disease on CT-assisted coronary arteriography and decreased and heterogeneous myocardial perfusion on contrast echocardiography secondary to both macro and microvascular coronary artery diseaseConclusions: Hypothyroidism is an important clinical situation and a risk factor to be considered for coronary artery involvement.text/html2014-05-06T11:16:52+01:00http://www.webmedcentral.com/Dr. Sourabh AggarwalRate of Heart failure guideline adherence in a tertiary care center in India after accounting for the therapeutic contraindications.
http://www.webmedcentral.com/article_view/4618
Introduction
Chronic heart failure (CHF) is a condition characterized by unpleasant symptoms, high mortality, and recurrent and lengthy hospitalizations. This study was done to determine the frequency of use of HF guideline recommended therapies in India.
Methods
The study was carried out in the department of cardiology at SMS Medical College and Hospital, Jaipur, Rajasthan. Patients with LVEF ≤45% on a recent transthoracic echocardiogram were selected. Adherence to each recommended medication class was defined as in hospital administration or outpatient prescription of at least 1 drug within the medication class prior to the recruitment date.
Results
A total of 308 patients were selected for this study. 223 (72.4%) patients were males and the mean age of all the patients was 51.5 ±13.5 years. Most of the patients (49.3%) were in NYHA class 2 at the time of recruitment and 29.2% were in NYHA class 3. Only 22 (7.1%) were in NYHA class 4.
After excluding the patients with contraindications, it was seen that 103 (46.6%) were receiving all the therapies recommended by the heart failure guidelines. Beta blockers and ACE-I’s/ARB’s were being prescribed to 88.8% and 96.5% respectively. Aldosterone antagonists were being prescribed to 73 (71.5%) patients after accounting for the contraindications. Guideline adherence for CRT and ICD was 40% and 9.3% respectively after making adjustments for patients with contraindications.
Conclusion
This study shows that percentage of patients receiving all guideline recommended therapies is lower in India as compared to the published western data. Fewer patients receiving CRT’s and ICD’s resulted in this difference and were the major contributors to this low adherence rates. Rates of guideline adherence for ACE-I’s/ARB’s, beta-blockers and aldosterone antagonists in our study was similar to the western data. text/html2015-09-14T09:27:26+01:00http://www.webmedcentral.com/Dr. Deepak GuptaClaustrophobia, Panic Attacks and Caffeine Intolerance may NOT be associated with Diastolic Dysfunction: A Pre-Echocardiogram Questionnaire-Based Pilot Study
http://www.webmedcentral.com/article_view/4975
Background: Diastolic heart dysfunction may explain the enigmatic pathophysiology of panic attacks and related disorders like claustrophobia, subjective/objective intolerance of heated enclosed environments and caffeine intolerance/allergy that can be sometimes indistinguishable from panic attacks symptomatically.
Objectives: To investigate whether clinical history of panic attacks-claustrophobia-caffeine intolerance is more common in patients with undiagnosed diastolic dysfunction who present for their outpatient echocardiogram tests.
Materials and Methods: Consenting adult outpatients who presented for their scheduled outpatient echocardiogram or stress echocardiogram at our University Hospital based Echocardiography Laboratory were asked to complete a questionnaire related to the clinical history of panic attacks, claustrophobia and caffeine intolerance. Spearman Rank Correlation and Partial Correlation Coefficients were used to correlate echocardiographic diastolic function grades with claustrophobia, panic attacks and caffeine intolerance based extracted (CP/CI/CPCI ) scores.
Results: Due to very small (n=40) pilot results (despite planned large-scale study at outset), we were only able to infer that: (a) there was only 75% inter-rater concordance in regards to diagnosing diastolic heart function on echocardiogram; (b) patients with diastolic heart dysfunction were significantly older; (c) 75% patients in our study pool were females; (d) diastolic heart dysfunction was prevalent in 45% patients; (e) there was very little (if any) clinical significance of CP/CI/CPCI scores in regards to predicting diastolic dysfunction grading; and (f) claustrophobia-panic attacks vs. caffeine-intolerance/allergy did not co-exist as co-morbidities in our set of patients.
Conclusion: Per our pre-echocardiogram questionnaire-based pilot study, claustrophobia, panic attacks and caffeine intolerance may NOT be associated with diastolic dysfunction.text/html2017-02-14T13:27:47+01:00http://www.webmedcentral.com/Dr. Deepak GuptaTo be, or Not to be - Apt William Shakespeare HAMLET Words Define Cardiopulmonary Resuscitation - CPR - Scenarios in India
http://www.webmedcentral.com/article_view/5254
Joshi (2015) [1] prospectively investigated cardiopulmonary resuscitation (CPR) in an Indian hospital scenario. However, the paper did not provide the reasons why 153 out of 413 in-hospital “witnessed” arrests were not considered for resuscitation attempts (the numbers, who did not qualify for CPR after in-hospital arrest, seem quite significant). If this data is assumed generalizable to the in-hospital population in India, it may seem that 37% of all in-hospital arrests in India may not qualify (and hence may NOT be considered) as candidates for CPR. This may reflect the ethical dilemmas of the Indian hospitals when dealing with the problematic clinical scenarios requiring CPR and emergency cardiovascular care (ECC). Primarily, this may be secondary to the absence of legal guidelines (local or national) about the advance directives for do-not-attempt-resuscitation (DNAR) despite the position statements (2014) by the Indian Society of Critical Care Medicine (ISCCM) [2] and the Indian Association of Palliative Care (IAPC) [3]. Nevertheless, it is my humble understanding that Joshi (2015) [1] should provide the explanations: (a) Were 153 patients excluded according to the study’s exclusion criteria? Excluded patients’ distribution among the corresponding exclusion criteria would be helpful; and if NOT then, (b) Were the patients’ surrogates included in the decision-making at the critical time of “witnessed” arrests? The CPR-withheld patients’ distribution among the corresponding reasons for not-resuscitating would be helpful. The American Heart Association (AHA) [4] addresses the CPR/ECC ethics by preferring withdrawal of life-support (after attempting CPR) over withholding CPR (when “witnessing” cardiac arrests). Unless there are DNAR orders in-situ, or patients dead irreversibly (clinically), or risks of physical injury to the CPR performers, CPR should be attempted. However, per the AHA 2000 guidelines [4], it seems ethical to withheld CPR in the non-viable newborns, and the deteriorating patients going into cardiac arrest in spite of their maximal and exhaustive in-hospital treatments. In summary, it is my humble reiteration that Joshi (2015) [1] should publish erratum as to why 153 patients out of 413 in-hospital “witnessed” arrests were not considered for CPR.text/html2017-10-24T06:51:59+01:00http://www.webmedcentral.com/Mr. Nilesh M PrashadA Critical Review of the Prevalence of Coronary Heart Disease in South Asians (Indians)
http://www.webmedcentral.com/article_view/5331
The prevalence of coronary heart disease (CHD) in South Asian (Indians) populations continues to be greater than the prevalence observed in people of European descent. The death rate attributed to CHD is also greatest in India. Through a combination of unique risk factors, potential causes for this observed difference in prevalence and potential changes in management are explored. In conclusion it is believed that differences in genetic, environmental and anatomical factors contribute the greatest to the high prevalence of CHD in South Asians (Indians).text/html2019-04-25T06:45:01+01:00http://www.webmedcentral.com/Dr. Deepak GuptaTrinity of Life: Brain-Heart-Lungs
http://www.webmedcentral.com/article_view/5560
As perioperative and critical care physicians, we are always encountering dilemmas about the definition of death. Without delving into philosophical intricacies about this definition from an individual’s perspective, I want to focus on how and when specific organs can be proclaimed dead wherein some organs’ deaths are almost always considered equivalent to deaths of the individual bodies harboring those dead organs. Historically, prior to mechanical ventilation era, people must have believed that if a person is not visibly breathing, that person must be already dead. Once the era of cardiopulmonary resuscitation (CPR) dawned, it must have become apparent to people that, until a person’s heart has given up on the person despite timely initiation of resuscitative efforts, that person can’t be pronounced dead. Now, the way the times are evolving to focus on protecting brains by cooling them down along with futuristic cryogenically frozen bodies harboring such protected brains [1-2], it may eventually turn out that clearly defined irreversible deaths for persons may become unquantifiable and mystical phenomena during the futuristic eras. In the interim, it can be said that lungs are “alive” when they are breathing naturally or artificially, hearts are “alive” when they are beating naturally or artificially, brains are “alive” when they are thinking naturally or artificially, and bodies are “alive” when these trinities of life are functioning as they are supposed to for the bodies harboring them. The time-sensitive thresholds and time-bound deadlines defining the reversibility of organ functions have evolved over time to eventually push back those times further and further when proclaiming the irreversible cessation of critical organs’ functions and thus prolonging the life history of modern human beings whereby pronouncing definitive irreversible deaths of bodies will eventually become more and more mystical.
To have a potential insight into such future, the recognition of fibrillating hearts will be so early in continuously monitored perioperative and critical care scenarios that the presence of conscious and communicating brains during these brief lag-periods within these monitored bodies harboring fibrillating hearts will confuse the rescuers and monitors alike just because these doomed brains haven’t yet caught up to the lack of pulsatile blood flow secondary to fibrillating and non-pumping hearts and are remaining conscious-communicative during these extremely brief lag-periods most likely due to imperfect non-zero non-zilch non-pulsatile blood circulating (delivering nutrients and extracting toxins) within their arterial-venous-capillary systems [3-11]. To further delve into such future, the recognition of hearts at potential risks of either “fibrillating thus non-pumping” or “non-pumping despite non-fibrillating” (asystole or pulseless electrical activity) will be so early during day-to-day lives of bodies harboring these potentially sick hearts that these bodies’ brains without worrying about natural hearts-initiated pulsatile blood reaching to them will be able to afford to remain conscious and communicative despite these bodies’ hearts eventually becoming irreversibly dead because with time these irreversibly dead natural hearts will become irrelevant when automated implantable cardiac devices will not only defibrillate and pace electronically but also compress mechanically buying the time for these bodies to get these irreversibly dead natural hearts replaced with artificial hearts ready to do the pumping of pulsatile blood throughout these bodies [12-13]. Finally, these so-called irreversibly dead bodies harboring non-breathing lungs, non-beating hearts and non-thinking brains will be able to get cryogenically frozen so early in time that their “lives” will get frozen in the space-time continuum to eventually get revived in toto wherein these supposedly dead bodies will be able to be alive again with their re-breathing lungs, re-beating hearts and re-thinking brains by making the leap in time to continue their “lives” from where they had “irreversibly” left thus making their “irreversibly-dead-and-frozen-time-periods” as irrelevant glitches in their space-time continuum [1-2].
Summarily for now, we should not be amazed or rattled or confused (a) when deciding to initiate CPR in conscious and communicating bodies demonstrating fibrillating hearts because these bodies’ brains will much sooner than later stop showing signs of thinking by losing their consciousness and ability to communicate [3], or (b) when deciding to sedate during CPR when effective CPR is inducing return of consciousness and ability to communicate sooner than later in those bodies whose natural hearts are failing immediately after withholding CPR thus warranting continuous effective CPR in those bodies harboring conscious and communicative brains in spite of harboring non-beating natural hearts [14-15].text/html2019-09-19T07:15:34+01:00http://www.webmedcentral.com/Dr. Deepak GuptaAdd Jaw-Thrust To Evolve 2-Rescuers Hands-Only CPR
http://www.webmedcentral.com/article_view/5593
Cardiocerebral resuscitation (CCR) as an evolved form of cardiopulmonary resuscitation (CPR) has been termed as Hands-Only CPR (HOCPR) for the lay rescuers.[1] iStan Adult Patient Simulator (CAE Healthcare, Saint-Laurent, Quebec, Canada) provides definitive evidence of “covert” pulmonary resuscitation happening during CCR. During a simulated clinical experience (SCE), end-tidal carbon dioxide (ETCO2) obtained at baseline was 25 mmHg (Figure 1A) when providing 788 ml tidal volume (TV) breaths during manual ventilation of intubated iStan. Subsequently obtained ETCO2 was 2 mmHg (Figure 1B) when HOCPR generated 102 ml TV “breaths” in non-ventilated iStan with endotracheal tube open-to-room-air. Although delivery of prematurely early breaths during manual ventilation miscalculated respiratory rate (Figure 1A), minute ventilation (MV) equated to ~10 breaths/min during 7.3 l/min manual ventilation paradoxically increased to 9.9 l/min when ~100 compressions/min HOCPR generated 102 ml TV “breaths” (HOCPR-induced-high-frequency-“ventilation”). Essentially, the SCE with intubated iStan is making the case for keeping airway-and-mouth open during HOCPR. Therefore, HOCPR training should devise SCE for 2-rescuers HOCPR wherein second lay rescuers are providing jaw thrust with their elbows resting on the floor (Figure 1C-1D) to comfortably sustain jaw thrust and keeping airway-and-mouth open for prolonged periods during HOCPR. Moreover, future investigators should document if they observe that, after the end of each exhalation, there is evidence of measurable ETCO2 as “cardiogenic oscillations” during each inspiratory downstroke in intubated and manually or mechanically ventilated patients during the times when they are receiving continuous chest compressions. Thereafter, they should explore whether controlling wind-speed around the open mouth can improve the “inhalability” of breathing zone room air in apneic mannequins.[2-3] Summarily, even though the above-mentioned observed evidence of pulmonary resuscitation during CCR (HOCPR) may need further exploration and validation studies, adding jaw thrust in the interim to evolve 2-rescuers HOCPR may only contribute to bettering the process of CPR. text/html2020-12-27T08:16:12+01:00http://www.webmedcentral.com/Dr. Deepak GuptaTape Fixture Or Phone Holder To Stably Hold Probe For Continuous Transthoracic Echocardiography
http://www.webmedcentral.com/article_view/5676
Analogous to old-school air-tight chest tube dressing, transthoracic echocardiography probe (wireless or portable or standard) can be fixed to the chest with silk or cloth tape as demonstrated on the mannequin (Figure A). This no-cost method had been originally envisaged by our team to potentially investigate and potentially document anatomical changes in healthy volunteers’ hearts while (a) their postures change from standing to sitting to supine to lateral to prone thus validating/refuting/reproducing experts’ historical results [1-5], and/or while (b) they are riding roller coasters thus validating/refuting/reproducing experts’ historical results [6-9]. Although artificial hearts may not demonstrate changes in anatomical shapes and anatomical positions which may be potentially associated with thrills and anxieties induced by roller coaster rides’ g-forces, persons with artificial hearts may still avoid roller coaster rides altogether due to their underlying cardiac diseases. In contrast to probe silk/cloth-taped in one fixed position, ProbeFix (Usono B.V., part of Medacc Holding B.V., Eindhoven, The Netherlands) may allow easy reorientation of stabilized probe among long axis and short axis views [10-11]. However due to multi-thousand cost of ProbeFix, the cost-efficient alternative may be easily purchasable – over the counter or online – phone holder to stabilize echocardiography probe on to the immobile and supine patients’ chests for intraoperative continuous transthoracic echocardiography as demonstrated with one-version of phone holder on the mannequin (Figure B). The feasibility to reorient among long axis and short axis views may depend on the flexibility and stability of phone holder’s chosen and available version because too many versions are available over the counter and online to choose from. Essentially, stabilized holding of transthoracic echocardiography probe is mechanically possible for various clinical applications of continuous non-invasive echocardiography, intraoperatively or otherwise.
FIGURE A-B
text/html2022-07-18T10:39:50+01:00http://www.webmedcentral.com/Dr. Deepak GuptaCompression-Ventilation Ratio Of 75:5 Per Minute Can Become 100:10 Per Minute From The Get-Go: Time To Mandate Continuous Quantitative Waveform Capnography During Cardiopulmonary Resuscitation As Bag-Valve-Mask Capnography May Allow Continuous Chest Compressions Without Pausing To Visualize Chest Rise
http://www.webmedcentral.com/article_view/5786
When we as anesthesia providers can no longer imagine providing anesthesia and even sedation to our even emergently boarded surgical patients without continuous quantitative waveform capnography, it is ironic that American Heart Association is awaiting more evidence before it can universally mandate its recommendation of continuous quantitative waveform capnography [1-3] during cardiopulmonary resuscitation despite it being the single monitor that can give real time glimpses into not only pulmonary resuscitation parameters but also cardiac resuscitation parameters especially when recognizing adequacy of mechanical or manual chest compressions-supported circulation transitioning into return of spontaneous circulation unless pulseless electrical activity is still persisting per continuous quantitative waveform capnography thus warranting to continue mechanical or manual chest compressions. It is interesting that how inconvenient it can be to attach continuous quantitative waveform capnography to HEPA filter's Luer port [4-5] for side-stream gas sampling line when HEPA filter is now universally recommended during cardiopulmonary resuscitation in evolving post-pandemic era. Unless continuous quantitative waveform capnography involves too high costs when universally accessible, it is amusing that anesthesia ventilators even for elective case scenarios universally have continuous quantitative waveform capnography while critical care unit ventilators [6-7] are yet to have continuous quantitative waveform capnography universally even for emergent case scenarios. Moreover, only time will tell whether continuous quantitative waveform capnography-based management may turn out to be more important than non-invasive blood pressure-based management for highly fluctuating hypotensive and very low cardiac output states during post-cardiac arrest care [8-10]. It is a question for a different time that why American Heart Association is still awaiting to recommend mechanical chest compressors [11-13] over manual chest compressors despite technology taking over and superseding most if not all aspects when dealing with emergencies to protect and save humans. Moreover, it is anybody's guess when American Heart Association will include ECPR (extracorporeal cardiopulmonary resuscitation [14-15]) in their routine algorithms so that ECPR comes first before switching on to correcting 5Hs and 5Ts of cardiac arrest if those corrective surgical and procedural interventions need access to intra/extra-thoracic areas thus precluding mechanical or manual chest compressions during such corrective surgical and procedural interventions. In the interim, American Heart Association can at least consider recommending use of bag-valve-mask capnography without any advanced airway devices in situ so that instead of 30:2 (effectively 75:5 per minute) compression-ventilation ratios, continuous chest compressions at 100:10 per minute compression-ventilation ratios can be continued from the get-go without pausing to visualize chest rise as a measure for adequacy of appropriately delivered capnography quantified breaths via bag-valve-mask devices with ample jaw thrust along with or without oropharyngeal/nasopharyngeal airway in situ. Moreover, there may be no hurry to hurriedly intubate patients and pause chest compressions for failed intubation attempts when able to effectively bag-valve-mask ventilate patients as visibly confirmed in real-time via continuous quantitative waveform capnography. Future may hold a vision for anesthesia providers carrying along mini-crash cart rather than mini-crash box/bag wherein besides one mechanical chest compressor system, there may be one continuous quantitative waveform capnography monitor with its complete setup plus invasive blood pressure monitor with its complete setup to leave by the patient's bedside to be retrieved later on after resuscitation has been completed or ceased thus requiring at least one additional replacement mechanical chest compressor system plus one additional replacement monitor equipped with above-mentioned two monitoring modalities available for anesthesia mini-crash cart all the time. The video-laryngoscopy plus ultrasound machine with vascular access probe and Doppler/Duplex capabilities on the same mini-crash cart may not be required to be left by the patient's bedside after tracheal intubation plus intravenous access as well as intra-arterial access have been successfully secured although Doppler/Duplex capabilities may help monitoring for return of spontaneous carotid/femoral pulsation [16-17] until intra-arterial access for invasive blood pressure monitoring has been secured. It may be even interesting to stock and restock this mini-crash cart with even central venous pressure monitoring capabilities [18-19] during cardiopulmonary resuscitation unless it may appear to be going too overboard just like the last resort carotid artery cannulation [20] for invasive blood pressure monitoring during cardiopulmonary resuscitation although intraosseus vascular access systems may have to already become an integral part of crash carts universally. Futuristically, after providing effective bilateral jaw-thrust [21] based bag-valve-mask ventilation as visible on continuous quantitative waveform capnography followed by successful endotracheal intubation of the patients with video-laryngoscopy for which pausing the chest compressions may or may not be required as similar to pausing the chest compressions may or may not be required for supraglottic airway device insertion [22-29], the anesthesia providers may immediately move on to radial or brachial artery cannulation [30-35] during the ongoing effective chest compressions which themselves may allow palpation of radial or brachial pulses thus making arterial cannulation to happen swiftly with or without ultrasound assistance well before the recurring resuscitative doses of intravenous epinephrine potentially making peripheral pulses unpalpable. As compared to non-invasive blood pressure monitoring, this invasive blood pressure monitoring along with continuous quantitative waveform capnography may allow overcoming near-hits-near-misses when impending or recurring pulseless electrical activity after return of spontaneous circulation may be happening due to very low cardiac output states during post-cardiac arrest care. text/html2022-09-28T01:53:31+01:00http://www.webmedcentral.com/Dr. Deepak GuptaMaybe Disease-Evolution Is All About Foods Which Are Either Biome-Enriching Or Biome-Depleting
http://www.webmedcentral.com/article_view/5795
Researchers are investigating prevalence of diseases in low- and middle-income countries (LMICs) to reshape health policy [1]. However, research data warrants an understanding how human diseases have been evolving to be rampantly prevalent amongst rich-educated in high-income countries (HICs) thence rich-educated in LMICs thence poor-uneducated in HICs and finally poor-uneducated in LMICs with expected reversal of this rampant prevalence in the same order. Fault is often found with foods [2]. However, the question is why humans cannot resist salt, sugar and fat (SSF) [3]. Evolution can answer that [4]. Physiologically essential SSF were scarcely and rarely available during our prehistory. Nature forced fasting on our ancestors who had to feast on SSF whenever available for short spans of time. Consequently, only those ancestral genes survived whose vehicles (ancestral bodies) tolerated feasting on SSF because ancestors whose genes were intolerant to SSF feasting perished before reproducing in absence of essential SSF. However, things went overboard when humans evolved artificially-produced SSF overabundance. Now, current disease-paradigm suggests that those whose taste buds can resist SSF feasting will outlive those whose cannot. This may force food-industrial complex to feed their bottom-lines with SSF-depleted foods. Interestingly, only time will tell whether artificially-induced SSF-scarcity will revive natural selection of descendants feasting on essential SSF. Herein, synbiotic foods correcting-enriching our multi-millennium-old symbiotic biomes and thus countering their ongoing rampant depletion by ultra-processed foods may play major role to either channelize scarce SSF or neutralize abundant SSF in our foods [5].