Behavioral intervention, nutrition, and exercise trials in heart failure.

With the aging of the population and advances in acute treatment of ischemic events and surgical techniques for coronary artery and valvular heart disease, the prevalence of heart failure has been increasing. Lifestyle modifications are an integral part of preventing and treating most pathologic human conditions, and include behavioral modifications, diet, and exercise. Despite advances in medical and device therapy for heart failure, clinicians still hope that patients will adhere to nonpharmacologic interventions, some of which can actually improve symptoms and quality of life. This article reviews the role of these lifestyle modifications in preventing and treating heart failure.

Acute myocardial infarction due to left anterior descending coronary artery dissection after blunt chest trauma.

Cardiac complications of chest trauma range from arrhythmias to valvular avulsions to myocardial contusion, rupture, and rarely myocardial infarction. We describe a case of a young patient with blunt chest trauma after a motor vehicle accident in whom the diagnosis of myocardial infarction was established a week later because no electrocardiogram or cardiac biomarkers were obtained on presentation. Retrospective review of contrast-enhanced computed tomography (CT) of the chest done on presentation demonstrated a perfusion defect in the distribution of the left anterior descending artery (LAD). Subsequent coronary angiography demonstrated dissection in the proximal LAD. Our case illustrates the importance of electrocardiography and contrast-enhanced chest CT in initial evaluation of patients with blunt chest trauma and suspected injury to the coronary arteries.

A case of spontaneous pneumothorax presenting with high-degree atrioventricular block.

The myocardial electrical conduction is significantly influenced by the sympathetic and parasympathetic nervous systems. Hypervagotonia refers to increased vagal tone leading to sinus bradycardia, sinus pause, or any degree of atrioventricular (AV) block. There are many clinical, electrocardiographic, and electrophysiologic clues that help make the diagnosis of hypervagotonia as the cause of bradyarrhythmias. We describe a case of spontaneous pneumothorax presenting with symptomatic high-degree AV block and subsequent electrophysiologic diagnosis of hypervagotonia. The patient had complete resolution of his bradycardia and AV block after chest tube placement. This case is intended to alert cardiologists to this rare presentation of spontaneous pneumothorax.

Rituximab-induced acute thrombocytopenia: a report of two cases.

Rituximab use in B-cell malignancies has been widely favored by the acceptable toxicity profile of this drug. Episodes of rituximab-induced neutropenia have been reported in some patients, but severe acute thrombocytopenia is very unusual. Here, we report transient severe acute thrombocytopenia after rituximab infusion in two patients with, one hairy cell leukemia the other with mantle cell lymphomay. Interestingly, in both cases, thrombocytopenia was reversible in a few days without further therapeutic intervention. The mechanism of this side effect remains unclear. Previous reports suggested the presence of CD20 antigen on the platelets themselves or that soluble CD20 antigen in the circulation may cause an antigen-antibody reaction and immune-mediated cell lysis. It is noteworthy that the two cases reported here as well as the two previously published cases share massive bone marrow involvement by neoplastic B lymphocytes.

Erysipelas of the upper extremity following locoregional therapy for breast cancer.

Cellulitis is a well-known complication of lymphedema of the lower extremities. Erysipelas of the upper extremity complicating breast cancer therapy has never been reported in the English-language literature. We describe seven breast cancer patients with erysipelas of the upper extremity. Five had a predisposing injury to the extremity. All patients responded very well to intravenous antibiotics without any sequelae. They had rapid resolution with typical desquamation. No long-term sequelae were seen except for mild increase of lymphedema. Erysipelas should be listed as a rare complication after locoregional therapy for breast cancer. Intravenous penicillin should be used as the initial therapy. Prevention of arm lymphedema and avoidance of any trauma to the arm are important prophylactic measures. Sentinel lymph node biopsy reduces the rate of axillary lymph node dissection and thus should reduce the incidence of lymphedema and erysipelas.

Incidence of urinary tract infection following transrectal ultrasound guided prostate biopsy at a tertiary-care medical center in Lebanon.

OBJECTIVE: To determine the incidence of urinary tract infections (UTIs) following transrectal ultrasound guided needle biopsy of the prostate (TRUBP) and the bacteriology of these infections. DESIGN: Retrospective evaluation of the charts and records of all patients who underwent TRUBP between June 1, 2002, and August 31, 2003. SETTING: American University of Beirut Medical Center, a tertiary-care center in Lebanon. PATIENTS: Two hundred seven patients underwent TRUBP. All received prophylactic antibiotics. One hundred twenty (58%) received ciprofloxacin alone, whereas 87 (42%) received both ciprofloxacin and gentamicin. Sixty-one patients (29.5%) had an enema prior to the procedure, whereas 146 (70.5%) did not. RESULTS: Thirteen patients (6.3%) were admitted with UTI. All had rigors and fever on admission. Symptoms appeared at a mean of 2.7 days and the mean hospital stay was 9.2 days. The mean duration of antibiotic treatment was 23.2 days. Ten (77%) of the patients had positive bacteriology. Urine cultures were positive in 8 (61.5%) of the patients and blood cultures in 6 (46.2%). All positive cultures grew Escherichia coli resistant to ciprofloxacin, with 5 isolates producing extended-spectrum betalactamases. CONCLUSIONS: TRUBP continues to be associated with significant infectious complications, especially UTI. Given the increasing incidence of antibiotic resistance mainly among the Enterobacteriaceae, antimicrobial prophylaxis practices should be reevaluated and the universal administration of quinolones alone or in combination with aminoglycosides should be reconsidered.

Treatment of heart failure with preserved ejection fraction: have we been pursuing the wrong paradigm?

Heart failure with preserved ejection fraction (HF-PEF) is the clinical syndrome of heart failure associated with normal or near-normal systolic function. Because inhibition of the adrenergic and renin-angiotensin-aldosterone systems has been so effective in the treatment of systolic heart failure, these same therapies have been the subject of recent clinical trials of HF-PEF. In this review, we examine the current evidence about treatment of HF-PEF, with particular emphasis on reviewing the literature for large-scale randomized clinical studies. The lack of significant benefit with neurohormonal antagonism in HF-PEF suggests that this condition might not involve neurohormonal activation as a critical pathophysiologic mechanism. Perhaps heart failure as we traditionally think of it is the wrong paradigm to pursue as we try to understand this condition of volume overload known as HF-PEF.

The STAT-MI (ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction) trial improves outcomes.

OBJECTIVES: The goal of this study was to evaluate the impact of the STAT-MI (ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction) network on outcomes in the treatment of patients presenting with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Shortening door-to-balloon (D2B) time remains a national priority for the treatment of STEMI. We previously reported a fully automated wireless network (STAT-MI) for transmission of electrocardiograms (ECGs) for suspected STEMI from the field to offsite cardiologists, allowing early triage with shortening of subsequent D2B times. We now report the impact of the STAT-MI wireless network on infarct size, length of hospital stay (LOS), and mortality. METHODS: A fully automated wireless network (STAT-MI) was developed to enable automatic 12-lead ECG transmission and direct communication between emergency medical services personnel and offsite cardiologists that facilitated direct triage of patients to the cardiac catheterization laboratory. Demographic, laboratory, and time interval data of STAT-MI network patients were prospectively collected over a 33-month period and compared with concurrent control patients who presented with STEMI through non-STAT-MI pathways. RESULTS: From June 2006 through February 2009, 92 patients presented via the STAT-MI network, and 50 patients presented through non-STAT-MI pathways (control group). Baseline clinical and demographic variables were similar in both groups. Overall, compared with control subjects, STAT-MI patients had significantly shorter D2B times (63 [42 to 87] min vs. 119 [96 to 178] min, U = 779.5, p < 0.00004), significantly lower peak troponin I (39.5 [11 to 120.5] ng/ml vs. 87.6 [38.4 to 227] ng/ml, U = 889.5, p = 0.005) and creatine phosphokinase-MB (126.1 [37.2 to 280.5] ng/ml vs. 290.3 [102.4 to 484] ng/ml, U = 883, p = 0.001), higher left ventricular ejection fractions (50% [35 to 55] vs. 35% [25 to 52], U = 1,075, p = 0.004), and shorter LOS (3 [2 to 4] days vs. 5.5 [3.5 to 10.5] days, U = 378, p < 0.001). CONCLUSIONS: A fully automated, field-based, wireless network that transmits ECGs automatically to offsite cardiologists for the early evaluation and triage of patients with STEMI shortens D2B times, reduces infarct size, limits ejection fraction reduction, and shortens LOS.

Optimizing primary PCI beyond "door to intervention time"--are we there yet?

AIM: To assess the effects of shortened door-to-intervention (DTI) time on appropriate clinical decisions regarding the four most critical and costly decisions during primary percutaneous coronary intervention (PCI): cath-lab activation (CLA), use of glycoprotein IIb/IIIa inhibitors (GPI), use of PCI, and deployment of drug-eluting stent (DES). BACKGROUND: STEMI PCI patients are frequently subject to decision making based on abbreviated medical encounter and limited medical information. METHODS: Clinical data were prospectively collected in a STEMI registry over 19 months. Retrospective chart reviews were conducted to determine the level of appropriateness of the above-mentioned decisions. RESULTS: Between June 2006 and December 2007, 200 EKGs with suspected STEMI were transmitted; 88 (44%) resulted in CLA. Compared to prior year, DTI times decreased from 145.7 to 69.9 min (P=.00001). DTI was longer during nights and weekends (87.5 vs. 51.8 min, P=.001) and the initial 6 months of the registry (86.8 vs. 66.8 min, P=.07). Nineteen (21.6%) of the patients undergoing angiography did not require revascularization, 56 (63.6%) received GPIs, and 65 patients (73.8%) underwent at least one vessel PCI, and at least one DES was used in 39 patients (60% of PCI cohort). When assessed for appropriateness, CLA was appropriate in 81.8% of the time and rendered borderline or inappropriate in 5.7% and 12.5%, respectively. GPI use was appropriate in 66% of the patients but seemed borderline or inappropriate in 28.5% and 5.4%, respectively. PCI was appropriate in 90% of the lesions treated, and borderline or inappropriate in 7.1% and 2.9%, respectively. DES use was viewed appropriate in 38.4%, and borderline or inappropriate in 51% and 10.2% of the DES deployments, respectively. CONCLUSIONS: (1) In view of expedited care, certain information required for decision-making process is either not available or ignored during primary PCI. (2) Appropriate use of resources in primary PCI needs to be better defined. (3) Measures of extracting patients' previous medical records and imaging studies along with in-lab immediate blood work and echocardiography and establishing new "time-out" protocols for STEMI patients may improve resource utilization and patient care and outcome.

Vasopressin and vasopressin receptor antagonists in heart failure.

Antidiuretic hormone, also known as arginine vasopressin, is a hormone with a multitude of physiologic activities including the control of urinary free water excretion. Antidiuretic hormone also plays a role in vasoconstriction and has 3 receptors that have been identified. Vasopressin analogs and antagonists have been extensively studied in animal models as well as in humans. Because heart failure is associated with a state of water retention, several vasopressin antagonists have been evaluated for their potential aquaretic effect. Diuretics remain the mainstay of treatment in acute and chronic volume overload but are not shown to improve survival. In fact, they are associated with numerous side effects including hypotension, electrolyte abnormalities, worsening renal function, and activation of renin-angiotensin-aldosternone system. Tolvaptan, conivaptan, and lixivaptan are some of the vasopressin antagonists that have been studied in heart failure. The results were initially encouraging with alleviation of symptoms and effective aquaresis without worsening of hyponatremia or renal function, but yet failed to show any effect on mortality in heart failure. With an increasing number of more selective orally active vasopressin antagonists, further studies are underway to establish the role of "Vaptans" in the treatment of heart failure and other disease states with volume overload and hyponatremia.