Taken to heart-arrhythmic potential of heart-leaf sida, a banned ephedrine alkaloid: a case report.

BACKGROUND: Ephedra and ephedrine alkaloids were commonly used in herbal supplements before being prohibited by the European Commission and US Food and Drug Administration. However, ongoing, unknowing use by consumers can lead to potential adverse cardiovascular effects, such as arrhythmias. CASE SUMMARY: A 65-year-old-man with a history of idiopathic pulmonary fibrosis status post-right single lung transplant was admitted for dizziness and resting tachycardia. Electrocardiogram showed a narrow complex, long R-P tachycardia with upright P-waves in lead V 1. An initial workup suggested an arrhythmia associated with the consumption of an herbal supplement containing heart-leaf sida, a banned botanical ephedrine alkaloid. After the supplement was discontinued, the patient's heart rate abruptly decreased without other intervention. Electrocardiogram showed a change in P-wave morphology in lead V 1 from upright to biphasic (+/-) after conversion to normal sinus rhythm. Thus, a diagnosis of atrial tachycardia originating at or near the donor right superior pulmonary vein was favoured. DISCUSSION: Atrial tachycardia can be precipitated by the proarrhythmic effects of ephedrine alkaloids, especially in patients with underlying risk factors and susceptible atrial anatomical substrate post-lung transplantation. Despite being banned by the European Union and the USA, ephedrine alkaloids continue to be used in over-the-counter herbal supplements and may go undetected by consumers. Ongoing vigilance for ephedrine alkaloids, more rigorous regulation, and active patient education can help reduce potential cardiovascular adverse events.

Incessant Atrial Tachycardia as First Presentation of Cardiac Angiosarcoma.

Primary cardiac angiosarcomas are rare malignant tumors with a very poor prognosis. We present a case of a 48-year-old man with no previous cardiac history who developed an incessant focal atrial tachycardia complicated by tachycardia-mediated cardiomyopathy as a consequence of cardiac angiosarcoma. (Level of Difficulty: Beginner.).

Atrial fibrillation: pathogenesis, medical-surgical management and dental implications.

BACKGROUND: Atrial fibrillation (AF) is a cardiac rhythm disturbance arising from disorganized electrical activity in the atria, and it is accompanied by an irregular and often rapid ventricular response. It is the most common clinically significant dysrhythmia in the general and older population. TYPES OF STUDIES REVIEWED: The authors conducted a MEDLINE search using the key terms "atrial fibrillation," "epidemiology," "pathophysiology," "treatment" and "dentistry." They selected contemporaneous articles published in peer-reviewed journals and gave preference to articles reporting randomized controlled trials. CLINICAL IMPLICATIONS: The anticoagulant warfarin frequently is prescribed to prevent stroke caused by cardiogenic thromboemboli arising from stagnant blood in poorly contracting atria. Most dental procedures and a limited number of surgical procedures can be performed without altering warfarin dosage if the international normalized ratio value is within the therapeutic range of 2.0 to 3.0. Certain analgesic agents, antibiotic agents, antifungal agents and sedative hypnotics, however, should not be prescribed without consultation with the patient's physician because these medications may alter the patient's risk of hemorrhage and stroke. CONCLUSIONS: AF affects nearly 2.5 million Americans, most of who are older than 60 years. Consultation with the patient's physician to discuss the planned dental treatment often is appropriate, especially for people who frequently have comorbid diseases such as coronary artery disease, congestive heart failure, diabetes and thyrotoxicosis, which are treated with multiple drug regimens.

Patient Characteristics and Clinical Outcomes with Low-Dose Dabigatran.

BACKGROUND/AIMS: Dabigatran, an oral direct thrombin inhibitor, is used in patients with non-valvular atrial fibrillation to reduce thromboembolic events. Whereas the 150 mg dosing regimen has been extensively studied in clinical setting, to date, there is no clinical data on the 75 mg (low dose, "LD") regimen. In this study, we evaluated patient characteristics and clinical outcomes in 49 patients treated with LD dabigatran. METHODS: Electronic medical records were utilized to compare patients from one medical center treated with LD dabigatran to those from the warfarin arm of the RE-LY trial. RESULTS: Compared to those from the warfarin arm of the RE-LY trial, the LD dabigatran patients were significantly older (82.6 vs. 71.6 years, p < 0.001), had higher prevalence of diabetes (42.9 vs. 23%, p < 0.001), were predominantly male (100 vs. 63.3%, p < 0.001), and had higher CHADS2 score (2.8 vs. 2.1, p < 0.001). Only 9 (18%) patients had creatinine clearance of <30 ml/min and none were on concomitant medications that required dose adjustment to LD dabigatran. During a mean follow up of 10.1 months, there were no thromboembolic events, no cerebrovascular events, and seven bleeding events in the LD dabigatran group of which only two required blood transfusion. CONCLUSION: In this database, most patients received LD dabigatran based on characteristics not related to the approved indications for this dose. The exploratory clinical outcomes of using LD dabigatran outside of the current approved indications are promising in this high-risk population and deserve further investigation to better understand the role of LD dabigatran in clinical practice.