1 Introduction Although older adults are generally among the highest users of cardiovascular medications, they are typically underrepresented or excluded from most efficacy and safety trials. Drug developers are usual...1 Introduction Although older adults are generally among the highest users of cardiovascular medications, they are typically underrepresented or excluded from most efficacy and safety trials. Drug developers are usually reluctant to include many senior adults in randomized controlled clinical trials in part due to their high prevalence of multiple comorbidities, frailty, and polypharmacy; and to age-related pharmacokinetic and pharmacodynamic complexities. Consequently, there is often insufficient high quality evidence-based data to inform pharmacologic management of common cardiovascular conditions on older adults. In the absence of data, clinicians often rely on conceptual principles regarding metabolism and drug-drug interactions to minimize adverse drug events, but this is often not well-substantiated or standardized. A related challenge is poor cardiovascular medication adherence among older adults, and its detrimental impact on their health outcomes. In this brief review we highlight some aspects of these topics.展开更多
Heart failure(HF)is a devastating condi-tion characterized by a high rate of mor-tality.[1]About 6.2 million individuals are grappling with the burden of HF in the United States(U.S).[2]Of this over 6 million individu...Heart failure(HF)is a devastating condi-tion characterized by a high rate of mor-tality.[1]About 6.2 million individuals are grappling with the burden of HF in the United States(U.S).[2]Of this over 6 million individuals af-fected with HF,a higher proportion is made up of people older than 65 years.[3,4]More than 50%of pa-tients hospitalized due HF are older than 75 years.[5]Seniors do not just account for the greater propor-tion of individuals affected by HF but also have a worse outcome compared to younger individuals with HF.[6−14]In the light of the above,we aim to address racial disparities as they affect seniors with HF in terms of mortality in addition to other potential prognostic indices.展开更多
Hypercalcemic crises as a result of milk-alkali syndrome(MAS)are an uncommon cause of altered mental status and acute renal failure in the emergency department.Although it is uncommonly reported in the emergency medic...Hypercalcemic crises as a result of milk-alkali syndrome(MAS)are an uncommon cause of altered mental status and acute renal failure in the emergency department.Although it is uncommonly reported in the emergency medicine literature,emergency physicians should be aware of this syndrome due to significant morbidity and mortality if left undiagnosed.展开更多
Human aging is a global issue with important implications for current and future incidence and prevalence of health conditions and disability. Cardiac arrhythmias, including atrial fibrillation, sudden cardiac death, ...Human aging is a global issue with important implications for current and future incidence and prevalence of health conditions and disability. Cardiac arrhythmias, including atrial fibrillation, sudden cardiac death, and bradycardia requiring pacemaker placement, all increase exponentially after the age of 60. It is important to distinguish between the normal, physiological consequences of aging on cardiac electrophysiology and the abnormal, pathological alterations. The age-related cardiac changes include ventricular hypertrophy, senile amyloidosis, cardiac valvular degenerative changes and annular calcification, fibrous infiltration of the conduction system, and loss of natural pacemaker cells and these changes could have a profound effect on the development of arrhythmias. The age-related cardiac electrophysiological changes include up- and down-regulation of specific ion channel expression and intmcellular Ca2＋ overload which promote the development of cardiac arrhythmias. As ion channels are the substrates of antiarrhythmic drugs, it follows that the pharmacokinetics and pharmacodynamics of these drugs will also change with age. Aging alters the absorption, distribution, metabolism, and elimination of antiarrhythmic drugs, so liver and kidney function must be monitored to avoid potential adverse drug effects, and antiarrhythmic dosing may need to be adjusted for age. Elderly patients are also more susceptible to the side effects of many antiarrhytbanics, including bradycardia, orthostatic hypotension, urinary retention, and falls. Moreover, the choice of antiarrhythmic drugs in the elderly patient is frequently complicated by the presence of co-morbid conditions and by polypharmacy, and the astute physician must pay careful attention to potential drug-drug interactions. Finally, it is important to remember that the use of antiarrhythmic drugs in elderly patients must be individualized and tailored to each patient＇s physiology, disease processes, and medication regimen.展开更多
Enhanced external counterpulsation Extemal counterpulsation （ECP） was originally conceived to be a circulatory assist device to promote blood flow to areas of the heart muscle that were lacking adequate blood suppl...Enhanced external counterpulsation Extemal counterpulsation （ECP） was originally conceived to be a circulatory assist device to promote blood flow to areas of the heart muscle that were lacking adequate blood supply due to obstruction of the coronary artery. During ECP the lower extremities are compressed to squeeze both arterial and venous blood back to the heart during diastole, increasing coronary perfusion pressure and right ventricular filling. The compression is released during systole,展开更多
Objective To explore the safety and efficacy of FFR-guided percutaneous coronary intervention (PCI) in vessels with severe diameter stenosis. Methods & Results Of 1090 patients undergoing fractional flow reserve (...Objective To explore the safety and efficacy of FFR-guided percutaneous coronary intervention (PCI) in vessels with severe diameter stenosis. Methods & Results Of 1090 patients undergoing fractional flow reserve (FFR) assessment from 2002 to 2009,we identified 167 patients in whom FFR was measured in at least one 70%–89% stenotic lesion. These patients were subdivided into an FFR-defer group (n = 49) if PCI was deferred (FFR > 0.80),and an FFR-perform group (n = 118) if PCI was performed (FFR ≤ 0.80). Comparatively,an additional 1176 patients undergoing PCI in at least one lesion with 70%–89% stenosis but without measurement of FFR served as a control (angiography- guided) group. Clinical outcomes were compared during a median follow-up of 49.0 months. The 5-year Kaplan-Meier estimated revascularization rates were 16% in the FFR-defer group and 33% in the FFR-perform group (P = 0.046). The incidence of major adverse cardiac events were comparable in these two groups (HR = 0.82,95% CI: 0.37–1.82,P = 0.63). The number of stents placed was significantly lower in the FFR-guided group (0.9 ± 0.8 vs. 1.4 ± 0.8,P < 0.001). Conclusions Functional revascularization for lesions with visually severe stenosis is clinically safe and associated with fewer stents use. This study suggests that extending the use of FFR to more severe coronary lesions may be reasonable.展开更多
BACKGROUND:While epinephrine is the recommended first-line therapy for the reversal of anaphylaxis symptoms,inappropriate use persists because of misunderstandings about proper dosing and administration or misconcepti...BACKGROUND:While epinephrine is the recommended first-line therapy for the reversal of anaphylaxis symptoms,inappropriate use persists because of misunderstandings about proper dosing and administration or misconceptions about its safety.The objective of this review was to evaluate the safety of epinephrine for patients with anaphylaxis,including other emergent conditions,treated in emergency care settings.METHODS:A MEDLINE search using PubMed was conducted to identify articles that discuss the dosing,administration,and safety of epinephrine in the emergency setting for anaphylaxis and other conditions.RESULTS:Epinephrine is safe for anaphylaxis when given at the correct dose by intramuscular injection.The majority of dosing errors and cardiovascular adverse reactions occur when epinephrine is given intravenously or incorrectly dosed.CONCLUSION:Epinephrine by intramuscular injection is a safe therapy for anaphylaxis but training may still be necessary in emergency care settings to minimize drug dosing and administration errors and to allay concerns about its safety.展开更多
Cardiac resynchronization therapy(CRT)has emerged as an important intervention for patients with heart failure(HF)with reduced ejection fraction and delayed ventricular activation.In these patients,CRT has demonstrate...Cardiac resynchronization therapy(CRT)has emerged as an important intervention for patients with heart failure(HF)with reduced ejection fraction and delayed ventricular activation.In these patients,CRT has demonstrated to improve quality of life,promote reverse left ventricular(LV)remodeling,reduce HF hospitalizations,and extend survival.However,despite advancements in our understanding of CRT,a significant number of patients do not respond to this therapy.Several invasive and non-invasive parameters have been assessed to predict response to CRT,but the electrocardiogram(ECG)has remained as the prevailing screening method albeit with limitations.Ideally,an accurate,simple,and reproducible ECG marker or set of markers would dramatically overcome the current limitations.We describe the clinical utility of an old ECG parameter that can estimate ventricular activation delay:the onset to intrinsicoid deflection(ID).Based on the concept of direct measurement of ventricular activation time(intrinsic deflection onset),time to ID onset measures on the surface ECG the time that the electrical activation time takes to reach the area subtended by the corresponding surface ECG lead.Based on this principle,the time to ID on the lateral leads can estimate the delay activation to the lateral LV wall and can be used as a predictor for CRT response,particularly in patients with non-specific intraventricular conduction delay or in patients with left bundle branch block and QRS<150 ms.The aim of this review is to present the current evidence and potential use of this ECG parameter to estimate LV activation and predict CRT response.展开更多
Background Endothelial function,as measured by big endothelin-1(ET-1),has been demonstrated to be useful in predicting adverse long-term events in patients with cardiovascular disease.Nevertheless,there are little dat...Background Endothelial function,as measured by big endothelin-1(ET-1),has been demonstrated to be useful in predicting adverse long-term events in patients with cardiovascular disease.Nevertheless,there are little data about the association between big ET-1 and thromboembolism risk in atrial fibrillation(AF).We aimed to investigate the relationship between big ET-1 and CHADS2/CHA2DS2-VASc scores used for evaluating thromboembolic risk in patients with non-valvular AF.Methods The study population consisted of 238 consecutive AF patients(67.6%with paroxysmal AF and 32.4%with persistent AF).The patients were divided into two groups(high-or low-intermediate risk group)based on CHADS2 and CHA2 DS2-VASc scores(score≥2 or<2,respectively).Clinical,laboratory,and echocardiographic parameters were evaluated,and the CHADS2/CHA2DS2-VASc scores were compared between groups.The association between big ET-1 levels and CHADS2/CHA2DS2-VASc score was assessed.Multivariate logistic regression analysis was performed to identify independent predictors of CHADS2/CHA2DS2-VASc scores.Results The high CHADS2/CHA2DS2-VASc score group had older age,higher big ET-1 levels,and enlarged left atrial diameter than the low CHADS2/CHA2DS2-VASc score group(P<0.05).Multiple logistic regression analysis revealed that big ET-1 level was an independent determinant of high CHADS2/CHA2DS2-VASc scores[odds ratio(OR)=2.545 and OR=3.816;both P<0.05].Conclusions Our study indicates that in non-valvular AF,big ET-1 was significantly correlated with CHADS2/CHA2DS2-VASc scores and an independent predictor of high CHADS2/CHA2DS2-VASc scores.Big ET-1 may serve as a useful marker for risk stratification in this setting.展开更多
1 Introduction? Mechanical circulatory support (MCS) has increasingly become an important management opportunity for patients with stage D heart failure (HF) with remarkable impact on patient survival and quality of l...1 Introduction? Mechanical circulatory support (MCS) has increasingly become an important management opportunity for patients with stage D heart failure (HF) with remarkable impact on patient survival and quality of life. Early clinical trials have demonstrated improved outcomes of durable left ventricular assist device (LVAD) support compared with optimal medical management.[1] As technology advanced, continuous flow LVADs outperformed pulsatile flow devices in clinical trials and the field migrated to HeartMate (Abbott Laboratories, Abbott Park, IL) and HeartWare (Medtronic, Minneapolis, MN) devices due to their clinical superiority. Among the continuous flow devices.展开更多
Elderly patients with acute myocardial infarction have not been specifically studied in the context of a large randomized clinical trial. Estimates of the efficacy of available treatments are gleaned from subset analy...Elderly patients with acute myocardial infarction have not been specifically studied in the context of a large randomized clinical trial. Estimates of the efficacy of available treatments are gleaned from subset analyses of clinical trials, retrospective analysis and singlecenter experiences. In western countries the population is aging and a disproportionate number of myocardial infarctions occur in the elderly. Usage of appropriate therapy in this age group is becoming increasingly important given the potential for benefit but also the potential for harm. Recent publications have found steady improvement in outcomes in the elderly population utilizing contemporary interventions.展开更多
Diabetic ketoacidosis remains one of the most serious complications of diabetes mellitus. Among its precipitating factors is myocardial ischemia, responsible for 1% of the cases of diabetic ketoacidosis.Ell Diabetic k...Diabetic ketoacidosis remains one of the most serious complications of diabetes mellitus. Among its precipitating factors is myocardial ischemia, responsible for 1% of the cases of diabetic ketoacidosis.Ell Diabetic ketoacidosis both with and without hyperkalemia has been reported to mimic a myocardial infarction pattem on ECG with ST segment elevation, described as pseudoinfarction pattern. Thus, it is important to raise awareness among physicians, as subjecting patients to invasive medical management can be avoided. We present a case of a 47-year-old female with diabetic ketoacidosis and hyperkalemia with initial ECG findings of ST segment elevation, but an urgent left heart catheterization revealed non-obstructive coronary disease.展开更多
Dear editor,Anaphylaxis and acute coronary syndromes(ACS)are discrete clinical presentations that usually present independently and are commonly treated in the emergency departments(EDs).[1]Kounis syndrome(KS)is a rar...Dear editor,Anaphylaxis and acute coronary syndromes(ACS)are discrete clinical presentations that usually present independently and are commonly treated in the emergency departments(EDs).[1]Kounis syndrome(KS)is a rare condition characterized by the coexistence of allergic reactions and ACS.KS was firstly described in detail by Kounis and Zavras in 1991 as an allergic angina syndrome.[2]The primary pathophysiological mechanism of KS is believed to be coronary artery vasospasm secondary to increased levels of infl ammatory mediators such as histamine,tryptase,platelet-activating factor,and various cytokines.[3]These inflammatory mediators are released through mast cell activation in response to a range of stimuli during episodes of allergic or hypersensitivity reactions.展开更多
Backgrounds ST-elevation myocardial infarction （STEMI） guidelines recommend reperfusion by primary percutaneous coronary in- tervention （PCI） ≤ 90 min from time of first medical contact （FMC）. This strategy is ...Backgrounds ST-elevation myocardial infarction （STEMI） guidelines recommend reperfusion by primary percutaneous coronary in- tervention （PCI） ≤ 90 min from time of first medical contact （FMC）. This strategy is challenging in rural areas lacking a nearby PCI-capable hospital. Recommended reperfusion times can be achieved for STEMI patients presenting in rural areas without a nearby PCI-capable hospital by ground transportation to a central PCI-capable hospital by use of protocol-driven emergency medical service （EMS） STEMI field triage protocol. Methods Sixty STEMI patients directly transported by EMS from three rural counties （Nassau, Camden and Charlton Counties） within a 50-mile radius of University of Florida Health-Jacksonville （UFHJ） from 01/01/2009 to 12/31/2013 were identified from its PCI registry. The STEMI field triage protocol incorporated three elements： （1） a cooperative agreement between each of the rural emergency medical service （EMS） agency and UFHJ; （2） performance of a pre-hospital ECG to facilitate STEMI identification and laboratory activation; and （3） direct transfer by ground transportation to the UFHJ cardiac catheterization laboratory. FMC-to-device （FMC2D）, door-to-device （D2D）, and transit times, the day of week, time of day, and EMS shift times were recorded, and odds ratio （OR） of achieving FMC2D times was calculated. Results FMC2D times were shorter for in-state STEMIs （81 ± 17 vs. 87± 19 min）, but D2D times were similar （37 ± 18 vs. 39 ± 21 min）. FMC2D 〈 90 min were achieved in 82.7% in-state STEMIs compared to 52.2% for out-of-state STEMIs （OR = 4.4, 95% CI： 1.24-15.57; P = 0.018）. FMC2D times were homogenous after adjusting for weekday vs. weekend, EMS shift times. Nine patients did not meet FMC2D ≤ 90 min. Six were within 10 min of target; all patient achieved FMC2D 〈 120 min. Conclusions Guideline-compliant FMC2D ≤90 min is achievable for rural STEMI patients within a 50 mile radius of a PCI-capable hospital by use of protocol-driven EMS ground transportation. As all patients achieved a FMC2D time 〈 120 min, bypass of non-PCI capable hospitals may be reasonable in this situation.展开更多
Introduction Heart failure （HF） is a major clinical manifestation of many cardiac disease processes when the cardiovascular compensatory mechanisms fail. Five million patients suffer from HF with an additional 555,...Introduction Heart failure （HF） is a major clinical manifestation of many cardiac disease processes when the cardiovascular compensatory mechanisms fail. Five million patients suffer from HF with an additional 555,000 new patients diagnosed HF annually. Moreover, there are an estimated 400,000 to 460,000 deaths attributable to sudden cardiac death （SCD） in the United States each year.1 Mortality in the heart failure population is about six to seven times higher than that of the agematched general population.展开更多
全基因组芯片已被推荐作为分析智力障碍、孤独症、多发性出生缺陷病因的首要筛查手段,通过芯片检查发现了人类基因组中大量的拷贝数变异(copy number variation,CNV),这些变异中既有正常个体的多态性,也有新发的致病性变异。为帮助临床...全基因组芯片已被推荐作为分析智力障碍、孤独症、多发性出生缺陷病因的首要筛查手段,通过芯片检查发现了人类基因组中大量的拷贝数变异(copy number variation,CNV),这些变异中既有正常个体的多态性,也有新发的致病性变异。为帮助临床实验室对芯片结果的解读保持一致性,美国医学遗传学会制定了此有关CNV的解读指南。该指南主要应用于产后的分子遗传诊断中。展开更多
BACKGROUND:Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting.Current guidelines recommend:1) quick diagnosis using standard criteri...BACKGROUND:Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting.Current guidelines recommend:1) quick diagnosis using standard criteria;2) first-line treatment with epinephrine;and 3) discharge with a prescription for an epinephrine auto-injector,written instructions regarding long-term management,and a referral(preferably,allergy) for follow-up.However,studies suggest low concordance with guideline recommendations by emergency medicine(EM) providers.The study aimed to evaluate how emergency departments(EDs) in the United States(US) manage anaphylaxis in relation to guideline recommendations.METHODS:This was an online anonymous survey of a random sample of EM health providers in US EDs.RESULTS:Data analysis included 207 EM providers.For respondent EDs,approximately 9%reported using agreed-upon clinical criteria to diagnose anaphylaxis;42%reported administering epinephrine in the ED for most anaphylaxis episodes;and <50%provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge.Most provided some written materials,and follow-up with a primary care clinician was recommended.CONCLUSIONS:This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis,treatment,and follow-up of patients with anaphylaxis.The primary gaps are low(or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine.Prospective research is recommended.展开更多
Restless legs syndrome(RLS)is a common sleep-related movement disorder characterised by an uncomfortable urge to move the legs that occurs during periods of inactivity.Although there have been many case reports on ant...Restless legs syndrome(RLS)is a common sleep-related movement disorder characterised by an uncomfortable urge to move the legs that occurs during periods of inactivity.Although there have been many case reports on antipsychotic-induced RLS,ziprasidone has never been reported as a cause of RLS.We present a case of a female patient with schizophrenia who presented with symptoms of RLS following the administration of high doses of ziprasidone added to quetiapine and valproate.The patient’s symptoms of RLS occurred following the administration and titration of ziprasidone to 160 mg,and were relieved upon reducing the dose to 120 mg/day.Other potential causative medications and differential diagnoses that could have caused similar symptoms were excluded.Clinicians should be aware of the potential for ziprasidone-induced RLS.Dopamine and serotonin interaction could be the mechanism underlying ziprasidone-induced RLS.展开更多
1 Introduction In an aging society with persistent high prevalence of cardiovascular disease （CVD） in the elderly population, the health care system is facing an increasing challenge to effectively care for these pa...1 Introduction In an aging society with persistent high prevalence of cardiovascular disease （CVD） in the elderly population, the health care system is facing an increasing challenge to effectively care for these patients. However, due to the under-representation of CVD patients over 75 years of age in clinical trials, assessing safety and efficacy of diagnostic and therapeutic approaches, the evidence for managing elderly CVD patients is especially limited. Physiological changes of aging intertwined with pathophysiology of CVD, and comorbid conditions often complicate clinical management.展开更多
文摘1 Introduction Although older adults are generally among the highest users of cardiovascular medications, they are typically underrepresented or excluded from most efficacy and safety trials. Drug developers are usually reluctant to include many senior adults in randomized controlled clinical trials in part due to their high prevalence of multiple comorbidities, frailty, and polypharmacy; and to age-related pharmacokinetic and pharmacodynamic complexities. Consequently, there is often insufficient high quality evidence-based data to inform pharmacologic management of common cardiovascular conditions on older adults. In the absence of data, clinicians often rely on conceptual principles regarding metabolism and drug-drug interactions to minimize adverse drug events, but this is often not well-substantiated or standardized. A related challenge is poor cardiovascular medication adherence among older adults, and its detrimental impact on their health outcomes. In this brief review we highlight some aspects of these topics.
文摘Heart failure(HF)is a devastating condi-tion characterized by a high rate of mor-tality.[1]About 6.2 million individuals are grappling with the burden of HF in the United States(U.S).[2]Of this over 6 million individuals af-fected with HF,a higher proportion is made up of people older than 65 years.[3,4]More than 50%of pa-tients hospitalized due HF are older than 75 years.[5]Seniors do not just account for the greater propor-tion of individuals affected by HF but also have a worse outcome compared to younger individuals with HF.[6−14]In the light of the above,we aim to address racial disparities as they affect seniors with HF in terms of mortality in addition to other potential prognostic indices.
文摘Hypercalcemic crises as a result of milk-alkali syndrome(MAS)are an uncommon cause of altered mental status and acute renal failure in the emergency department.Although it is uncommonly reported in the emergency medicine literature,emergency physicians should be aware of this syndrome due to significant morbidity and mortality if left undiagnosed.
文摘Human aging is a global issue with important implications for current and future incidence and prevalence of health conditions and disability. Cardiac arrhythmias, including atrial fibrillation, sudden cardiac death, and bradycardia requiring pacemaker placement, all increase exponentially after the age of 60. It is important to distinguish between the normal, physiological consequences of aging on cardiac electrophysiology and the abnormal, pathological alterations. The age-related cardiac changes include ventricular hypertrophy, senile amyloidosis, cardiac valvular degenerative changes and annular calcification, fibrous infiltration of the conduction system, and loss of natural pacemaker cells and these changes could have a profound effect on the development of arrhythmias. The age-related cardiac electrophysiological changes include up- and down-regulation of specific ion channel expression and intmcellular Ca2＋ overload which promote the development of cardiac arrhythmias. As ion channels are the substrates of antiarrhythmic drugs, it follows that the pharmacokinetics and pharmacodynamics of these drugs will also change with age. Aging alters the absorption, distribution, metabolism, and elimination of antiarrhythmic drugs, so liver and kidney function must be monitored to avoid potential adverse drug effects, and antiarrhythmic dosing may need to be adjusted for age. Elderly patients are also more susceptible to the side effects of many antiarrhytbanics, including bradycardia, orthostatic hypotension, urinary retention, and falls. Moreover, the choice of antiarrhythmic drugs in the elderly patient is frequently complicated by the presence of co-morbid conditions and by polypharmacy, and the astute physician must pay careful attention to potential drug-drug interactions. Finally, it is important to remember that the use of antiarrhythmic drugs in elderly patients must be individualized and tailored to each patient＇s physiology, disease processes, and medication regimen.
文摘Enhanced external counterpulsation Extemal counterpulsation （ECP） was originally conceived to be a circulatory assist device to promote blood flow to areas of the heart muscle that were lacking adequate blood supply due to obstruction of the coronary artery. During ECP the lower extremities are compressed to squeeze both arterial and venous blood back to the heart during diastole, increasing coronary perfusion pressure and right ventricular filling. The compression is released during systole,
基金supported by the National Institute of Health (NIH Grant HL-92954 and AG-31750 to A.L)supported by an unrestricted grant from St Jude Medical+1 种基金supported by the National Natural Science Foundation of China (No.81470491)the Beijing Municipal Natural Science Foundation (No. 7192078)
文摘Objective To explore the safety and efficacy of FFR-guided percutaneous coronary intervention (PCI) in vessels with severe diameter stenosis. Methods & Results Of 1090 patients undergoing fractional flow reserve (FFR) assessment from 2002 to 2009,we identified 167 patients in whom FFR was measured in at least one 70%–89% stenotic lesion. These patients were subdivided into an FFR-defer group (n = 49) if PCI was deferred (FFR > 0.80),and an FFR-perform group (n = 118) if PCI was performed (FFR ≤ 0.80). Comparatively,an additional 1176 patients undergoing PCI in at least one lesion with 70%–89% stenosis but without measurement of FFR served as a control (angiography- guided) group. Clinical outcomes were compared during a median follow-up of 49.0 months. The 5-year Kaplan-Meier estimated revascularization rates were 16% in the FFR-defer group and 33% in the FFR-perform group (P = 0.046). The incidence of major adverse cardiac events were comparable in these two groups (HR = 0.82,95% CI: 0.37–1.82,P = 0.63). The number of stents placed was significantly lower in the FFR-guided group (0.9 ± 0.8 vs. 1.4 ± 0.8,P < 0.001). Conclusions Functional revascularization for lesions with visually severe stenosis is clinically safe and associated with fewer stents use. This study suggests that extending the use of FFR to more severe coronary lesions may be reasonable.
文摘BACKGROUND:While epinephrine is the recommended first-line therapy for the reversal of anaphylaxis symptoms,inappropriate use persists because of misunderstandings about proper dosing and administration or misconceptions about its safety.The objective of this review was to evaluate the safety of epinephrine for patients with anaphylaxis,including other emergent conditions,treated in emergency care settings.METHODS:A MEDLINE search using PubMed was conducted to identify articles that discuss the dosing,administration,and safety of epinephrine in the emergency setting for anaphylaxis and other conditions.RESULTS:Epinephrine is safe for anaphylaxis when given at the correct dose by intramuscular injection.The majority of dosing errors and cardiovascular adverse reactions occur when epinephrine is given intravenously or incorrectly dosed.CONCLUSION:Epinephrine by intramuscular injection is a safe therapy for anaphylaxis but training may still be necessary in emergency care settings to minimize drug dosing and administration errors and to allay concerns about its safety.
文摘Cardiac resynchronization therapy(CRT)has emerged as an important intervention for patients with heart failure(HF)with reduced ejection fraction and delayed ventricular activation.In these patients,CRT has demonstrated to improve quality of life,promote reverse left ventricular(LV)remodeling,reduce HF hospitalizations,and extend survival.However,despite advancements in our understanding of CRT,a significant number of patients do not respond to this therapy.Several invasive and non-invasive parameters have been assessed to predict response to CRT,but the electrocardiogram(ECG)has remained as the prevailing screening method albeit with limitations.Ideally,an accurate,simple,and reproducible ECG marker or set of markers would dramatically overcome the current limitations.We describe the clinical utility of an old ECG parameter that can estimate ventricular activation delay:the onset to intrinsicoid deflection(ID).Based on the concept of direct measurement of ventricular activation time(intrinsic deflection onset),time to ID onset measures on the surface ECG the time that the electrical activation time takes to reach the area subtended by the corresponding surface ECG lead.Based on this principle,the time to ID on the lateral leads can estimate the delay activation to the lateral LV wall and can be used as a predictor for CRT response,particularly in patients with non-specific intraventricular conduction delay or in patients with left bundle branch block and QRS<150 ms.The aim of this review is to present the current evidence and potential use of this ECG parameter to estimate LV activation and predict CRT response.
基金supported by the National Natural Science Foundation of China(No.81600275)
文摘Background Endothelial function,as measured by big endothelin-1(ET-1),has been demonstrated to be useful in predicting adverse long-term events in patients with cardiovascular disease.Nevertheless,there are little data about the association between big ET-1 and thromboembolism risk in atrial fibrillation(AF).We aimed to investigate the relationship between big ET-1 and CHADS2/CHA2DS2-VASc scores used for evaluating thromboembolic risk in patients with non-valvular AF.Methods The study population consisted of 238 consecutive AF patients(67.6%with paroxysmal AF and 32.4%with persistent AF).The patients were divided into two groups(high-or low-intermediate risk group)based on CHADS2 and CHA2 DS2-VASc scores(score≥2 or<2,respectively).Clinical,laboratory,and echocardiographic parameters were evaluated,and the CHADS2/CHA2DS2-VASc scores were compared between groups.The association between big ET-1 levels and CHADS2/CHA2DS2-VASc score was assessed.Multivariate logistic regression analysis was performed to identify independent predictors of CHADS2/CHA2DS2-VASc scores.Results The high CHADS2/CHA2DS2-VASc score group had older age,higher big ET-1 levels,and enlarged left atrial diameter than the low CHADS2/CHA2DS2-VASc score group(P<0.05).Multiple logistic regression analysis revealed that big ET-1 level was an independent determinant of high CHADS2/CHA2DS2-VASc scores[odds ratio(OR)=2.545 and OR=3.816;both P<0.05].Conclusions Our study indicates that in non-valvular AF,big ET-1 was significantly correlated with CHADS2/CHA2DS2-VASc scores and an independent predictor of high CHADS2/CHA2DS2-VASc scores.Big ET-1 may serve as a useful marker for risk stratification in this setting.
文摘1 Introduction? Mechanical circulatory support (MCS) has increasingly become an important management opportunity for patients with stage D heart failure (HF) with remarkable impact on patient survival and quality of life. Early clinical trials have demonstrated improved outcomes of durable left ventricular assist device (LVAD) support compared with optimal medical management.[1] As technology advanced, continuous flow LVADs outperformed pulsatile flow devices in clinical trials and the field migrated to HeartMate (Abbott Laboratories, Abbott Park, IL) and HeartWare (Medtronic, Minneapolis, MN) devices due to their clinical superiority. Among the continuous flow devices.
文摘Elderly patients with acute myocardial infarction have not been specifically studied in the context of a large randomized clinical trial. Estimates of the efficacy of available treatments are gleaned from subset analyses of clinical trials, retrospective analysis and singlecenter experiences. In western countries the population is aging and a disproportionate number of myocardial infarctions occur in the elderly. Usage of appropriate therapy in this age group is becoming increasingly important given the potential for benefit but also the potential for harm. Recent publications have found steady improvement in outcomes in the elderly population utilizing contemporary interventions.
文摘Diabetic ketoacidosis remains one of the most serious complications of diabetes mellitus. Among its precipitating factors is myocardial ischemia, responsible for 1% of the cases of diabetic ketoacidosis.Ell Diabetic ketoacidosis both with and without hyperkalemia has been reported to mimic a myocardial infarction pattem on ECG with ST segment elevation, described as pseudoinfarction pattern. Thus, it is important to raise awareness among physicians, as subjecting patients to invasive medical management can be avoided. We present a case of a 47-year-old female with diabetic ketoacidosis and hyperkalemia with initial ECG findings of ST segment elevation, but an urgent left heart catheterization revealed non-obstructive coronary disease.
文摘Dear editor,Anaphylaxis and acute coronary syndromes(ACS)are discrete clinical presentations that usually present independently and are commonly treated in the emergency departments(EDs).[1]Kounis syndrome(KS)is a rare condition characterized by the coexistence of allergic reactions and ACS.KS was firstly described in detail by Kounis and Zavras in 1991 as an allergic angina syndrome.[2]The primary pathophysiological mechanism of KS is believed to be coronary artery vasospasm secondary to increased levels of infl ammatory mediators such as histamine,tryptase,platelet-activating factor,and various cytokines.[3]These inflammatory mediators are released through mast cell activation in response to a range of stimuli during episodes of allergic or hypersensitivity reactions.
文摘Backgrounds ST-elevation myocardial infarction （STEMI） guidelines recommend reperfusion by primary percutaneous coronary in- tervention （PCI） ≤ 90 min from time of first medical contact （FMC）. This strategy is challenging in rural areas lacking a nearby PCI-capable hospital. Recommended reperfusion times can be achieved for STEMI patients presenting in rural areas without a nearby PCI-capable hospital by ground transportation to a central PCI-capable hospital by use of protocol-driven emergency medical service （EMS） STEMI field triage protocol. Methods Sixty STEMI patients directly transported by EMS from three rural counties （Nassau, Camden and Charlton Counties） within a 50-mile radius of University of Florida Health-Jacksonville （UFHJ） from 01/01/2009 to 12/31/2013 were identified from its PCI registry. The STEMI field triage protocol incorporated three elements： （1） a cooperative agreement between each of the rural emergency medical service （EMS） agency and UFHJ; （2） performance of a pre-hospital ECG to facilitate STEMI identification and laboratory activation; and （3） direct transfer by ground transportation to the UFHJ cardiac catheterization laboratory. FMC-to-device （FMC2D）, door-to-device （D2D）, and transit times, the day of week, time of day, and EMS shift times were recorded, and odds ratio （OR） of achieving FMC2D times was calculated. Results FMC2D times were shorter for in-state STEMIs （81 ± 17 vs. 87± 19 min）, but D2D times were similar （37 ± 18 vs. 39 ± 21 min）. FMC2D 〈 90 min were achieved in 82.7% in-state STEMIs compared to 52.2% for out-of-state STEMIs （OR = 4.4, 95% CI： 1.24-15.57; P = 0.018）. FMC2D times were homogenous after adjusting for weekday vs. weekend, EMS shift times. Nine patients did not meet FMC2D ≤ 90 min. Six were within 10 min of target; all patient achieved FMC2D 〈 120 min. Conclusions Guideline-compliant FMC2D ≤90 min is achievable for rural STEMI patients within a 50 mile radius of a PCI-capable hospital by use of protocol-driven EMS ground transportation. As all patients achieved a FMC2D time 〈 120 min, bypass of non-PCI capable hospitals may be reasonable in this situation.
文摘Introduction Heart failure （HF） is a major clinical manifestation of many cardiac disease processes when the cardiovascular compensatory mechanisms fail. Five million patients suffer from HF with an additional 555,000 new patients diagnosed HF annually. Moreover, there are an estimated 400,000 to 460,000 deaths attributable to sudden cardiac death （SCD） in the United States each year.1 Mortality in the heart failure population is about six to seven times higher than that of the agematched general population.
文摘全基因组芯片已被推荐作为分析智力障碍、孤独症、多发性出生缺陷病因的首要筛查手段,通过芯片检查发现了人类基因组中大量的拷贝数变异(copy number variation,CNV),这些变异中既有正常个体的多态性,也有新发的致病性变异。为帮助临床实验室对芯片结果的解读保持一致性,美国医学遗传学会制定了此有关CNV的解读指南。该指南主要应用于产后的分子遗传诊断中。
基金supported in part by an unrestricted educational grant from Mylan Specialty Pharmaceuticals(Basking Ridge,NJ)
文摘BACKGROUND:Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting.Current guidelines recommend:1) quick diagnosis using standard criteria;2) first-line treatment with epinephrine;and 3) discharge with a prescription for an epinephrine auto-injector,written instructions regarding long-term management,and a referral(preferably,allergy) for follow-up.However,studies suggest low concordance with guideline recommendations by emergency medicine(EM) providers.The study aimed to evaluate how emergency departments(EDs) in the United States(US) manage anaphylaxis in relation to guideline recommendations.METHODS:This was an online anonymous survey of a random sample of EM health providers in US EDs.RESULTS:Data analysis included 207 EM providers.For respondent EDs,approximately 9%reported using agreed-upon clinical criteria to diagnose anaphylaxis;42%reported administering epinephrine in the ED for most anaphylaxis episodes;and <50%provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge.Most provided some written materials,and follow-up with a primary care clinician was recommended.CONCLUSIONS:This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis,treatment,and follow-up of patients with anaphylaxis.The primary gaps are low(or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine.Prospective research is recommended.
基金This case report was funded by Psychosomatic Medicine Project of Key Developing Disciplines of Shanghai Municipal Health Commission(2019ZB0202)in China.
文摘Restless legs syndrome(RLS)is a common sleep-related movement disorder characterised by an uncomfortable urge to move the legs that occurs during periods of inactivity.Although there have been many case reports on antipsychotic-induced RLS,ziprasidone has never been reported as a cause of RLS.We present a case of a female patient with schizophrenia who presented with symptoms of RLS following the administration of high doses of ziprasidone added to quetiapine and valproate.The patient’s symptoms of RLS occurred following the administration and titration of ziprasidone to 160 mg,and were relieved upon reducing the dose to 120 mg/day.Other potential causative medications and differential diagnoses that could have caused similar symptoms were excluded.Clinicians should be aware of the potential for ziprasidone-induced RLS.Dopamine and serotonin interaction could be the mechanism underlying ziprasidone-induced RLS.
文摘1 Introduction In an aging society with persistent high prevalence of cardiovascular disease （CVD） in the elderly population, the health care system is facing an increasing challenge to effectively care for these patients. However, due to the under-representation of CVD patients over 75 years of age in clinical trials, assessing safety and efficacy of diagnostic and therapeutic approaches, the evidence for managing elderly CVD patients is especially limited. Physiological changes of aging intertwined with pathophysiology of CVD, and comorbid conditions often complicate clinical management.
