Flecainide toxicity associated with the use of goji berries: a case report.

BACKGROUND: Goji berries (GB), usually marketed as a 'superfruit', are a widely used herbal supplement. As with other herbal remedies, the use of GB might be associated with herb-drug interactions, increasing plasma levels of other drugs and causing adverse events. Here, we present the case of a patient that developed flecainide toxicity secondary to an herb-drug interaction, associated with the use of GB to prevent COVID-19. CASE SUMMARY: A 75-year-old female presented to the emergency department with fainting. She was taking flecainide for the treatment of atrial extrasystoles diagnosed 2 years previously, and she was using a tea of GB for the prevention of COVID-19. The admission electrocardiogram showed a wide complex polymorphic tachycardia that was considered and treated as flecainide toxicity. The patient had a favourable evolution and was discharged 48 h after admission. DISCUSSION: Flecainide toxicity is uncommon and needs timely recognition and treatment; it is usually secondary to overdose and renal or hepatic failure. In our case, toxicity was associated with GB use, probably by inhibition of CYP2D6 which is the main enzyme associated with the metabolism of flecainide. Clinicians need to be aware of the possible interactions between herbal remedies (in this case used for the prevention of COVID-19) and cardiovascular drugs that are used to treat chronic cardiovascular diseases.

Declaración ante los resultados del ensayo clínico Symplicity HTN 3. Grupo de estudio de la hipertensión arterial resistente / Position paper on the results of Symplicity HTN-3 trial. Grupo de estudio de la hipertensión arterial resistente

La denervación de las arterias renales ha sido una alternativa para el tratamiento de la hipertensión arterial resistente. Los estudios Symplicity HTN 1 y 2 mostraron en grupos pequeños y no controlados disminuciones de la presión sistólica hasta de 30 mm Hg. Este entusiasmo ha sido opacado por el estudio Symplicity HTN 3, ensayo clínico aleatorizado y controlado con un procedimiento placebo. Sorprendentemente, los resultados sugirieron que la denervación renal tuvo un efecto similar al del placebo, aunque en el análisis de subgrupos preespecificados los pacientes que no eran de raza negra, los menores de 65 años y los que tenían función renal normal tuvieron una reducción de la presión arterial sistólica estadísticamente significativa. Esta es una evaluación crítica de los resultados del Symplicity HTN 3 y propone posibles explicaciones para estos. Además, declara la postura de nuestro grupo y las acciones futuras.

Renal artery denervation has shown to be an effective treatment for resistant hypertension. Symplicity HTN 1 and 2 trials showed in small and uncontrolled groups, significant systolic blood pressure reductions down to 30 mm Hg. Symplicity HTN-3, a double blind, randomized, placebo controlled clinical trial shaded this initial enthusiasm. Surprisingly, their results showed that renal denervation has a similar effect to placebo. Pre-specified subgroup analysis showed that non-black race individuals, younger than 65 years and with normal renal function, had a statistically significant systolic blood pressure decrease. This manuscript critically appraises the Symplicity HTN-3 trial, proposing possible explanations for the results. Also declares our group position and future actions regarding renal denervation.

[Position paper on the results of Symplicity HTN-3 trial. Grupo de estudio de la hipertensión arterial resistente]. / Declaración ante los resultados del ensayo clínico Symplicity HTN 3. Grupo de estudio de la hipertensión arterial resistente.

Renal artery denervation has shown to be an effective treatment for resistant hypertension. Symplicity HTN 1 and 2 trials showed in small and uncontrolled groups, significant systolic blood pressure reductions down to 30 mm Hg. Symplicity HTN-3, a double blind, randomized, placebo controlled clinical trial shaded this initial enthusiasm. Surprisingly, their results showed that renal denervation has a similar effect to placebo. Pre-specified subgroup analysis showed that non-black race individuals, younger than 65 years and with normal renal function, had a statistically significant systolic blood pressure decrease. This manuscript critically appraises the Symplicity HTN-3 trial, proposing possible explanations for the results. Also declares our group position and future actions regarding renal denervation.

Effect of physician training on the X-ray dose delivered during coronary angioplasty.

OBJECTIVE: To assess whether physician training helps decrease the amount of radiation delivered to patients undergoing coronary angioplasty with stent placement. BACKGROUND: Coronary angioplasty exposes patients to high doses of ionizing radiation, possibly related to equipment misuse or inappropriate training. METHODS: Reference point air kerma (K(a,r)) and kerma area product (P(KA)) were prospectively registered during a period of 6 months in patients undergoing coronary angiography and angioplasty with stent ad hoc. All interventionalists were then invited to an informative conference on appropriate use of radiation and changes in x-ray delivery settings. Data were recorded during the following 6 months and then compared for the whole group and for those who did or did not attend the conference. RESULTS: K(a,r) decreased from 5.44 ± 0.3 Gy (n = 106) to 3.39 ± 0.22 Gy (n = 112); P<.0001 and P(KA) decreased from 365.4 ± 21.1 Gy·cm(-2); to 233.7 ± 13.1 Gy·cm(-2); P<.0001. During the first 6 months, there were no differences in radiation emitted among physicians; however, during the second half of the study, there was a 34% difference in K(a,r) between those that attended the conference and those who did not (2.78 ± 0.23 Gy vs 4.18 ± 0.37 Gy; P=.002), regardless of the fact that both groups lowered radiation emission settings. CONCLUSION: Changes in x-ray parameters profoundly reduce the amount of radiation delivered to patients, a situation that was more evident in those who attended an informative conference. It is important to educate cardiologists in the appropriate use of modern x-ray equipment.

[Evaluation of left ventricular function with a 16-slice multidetector tomograph (MDCT-16): correlation with cardiovascular magnetic resonance imaging]. / Valoración de la función ventricular con tomografía computarizada de 16 detectores (TCMD-16): correlación con resonancia magnética cardiovascular.

UNLABELLED: The evaluation of Left ventricular function has both prognostic as well as therapeutic implications in patients with heart disease. Non-invasive coronary angiography with computed tomography using 16 slices (MDCT-16) allows to obtain images of the coronary anatomy due to its high spatial and temporal resolution, and also, to obtain data regarding Left ventricular function. The objective of this study was to correlate the use of MDCT-16 for the evaluation of the Left ventricular parameters using MRI as the Standard of reference. METHODS: MRI: Se A 1.5 Tesla GE CvI Scanner optimized for cardiovascular applications was used. Using an ECG gated steady state fast precession sequence (SSFP, Thickness 10 mm, Flip Angle 45, FOV 36 cm. NEX 1, Frequency 256, Phase 128, Partial FOV 0.75, 16VPS), 6 to 8 short axis images of from base to apex of the left ventricle were obtained. Tomography: Using a 16 slice Multidetector tomograph (GE Lightspeed) and using ECG synchronization, images of the heart were obtained after the administration of 80 mls. of no-ionic contrast. The images were reconstructed off-line to obtain from 6 to 8 slices in a similar fashion to that of MR. Both studies were independently analyzed by 2 operators who obtained the ventricular function data. Linear correlation and a Paired T Student test was used to analyze the data and was considered significant when p < 0.05. RESULTS: 20 consecutive patients were evaluated with MDCT-16 and MRI, 18 males, mean age 52 +/- 15 years. There was no significant difference among the measurements for cardiac CT and MRI of the end-diastolic volume (EDV) and end-sistolic volume (ESV), stroke volume (SV), LV Mass or LV ejection fraction (LVEF). CONCLUSION: This results show a high correlation among the clinically relevant ventricular function parameters evaluated by cardiovascular CT and MRI. This findings suggest that ventricular function can be successfully evaluated along with the coronary anatomy using MDCT-16.

Valoración de la función ventricular con tomografía computarizada de 16 detectores (TCMD-16): Correlación con resonancia magnética cardiovascular / Evaluation of left ventricular function with a 16-slice multidetector tomograph (MDCT-16): Correlation with cardiovascular magnetic resonance imaging

La evaluación de parámetros funcionales del VI tienen implicaciones tanto pronosticas como terapéuticas en pacientes con cardiopatías. La angiotomografía coronaria con TCMD-16 permite obtener imágenes de la anatomía coronaria y por su alta resolución temporal y espacial, obtener datos de la función ventricular izquierda. El objetivo de este estudio fue correlacionar el uso de la TCMD-16 para la valoración de parámetros de función ventricular izquierda, utilizando la RM como estándar de referencia. Métodos: Resonancia: Se utilizó un resonador GE Cvl, de 1.5 Teslas optimizado para aplicaciones cardiovasculares. Mediante una secuencia de precesión rápida de estado fijo de manera sincronizada al ECG, (SSFP, Grosor de corte de 10 mm, Flip Angle 45, FOV 36 cm., NEX 1, Frecuencia 256, Fase 128, FOV parcial 0.75, 16 VPS), se obtuvieron de 6 a 8 imágenes en eje corto desde la base hasta el ápex del VI. Tomografía: Con un TCMD-16 GE Lightspeed sincronizado al ECG, se obtuvieron imágenes del corazón tras la administración de 80 mis. de contraste no-iónico. Las imágenes fueron reconstruidas para obtener de 6 a 8 cortes de manera similar a la RM. Ambos estudios fueron independientemente analizados por 2 operadores quienes obtuvieron los parámetros ventriculares. Las comparaciones fueron analizadas mediante la prueba de t de Student pareada y las correlaciones mediante regresión linear, considerando significativo cuando p<0.05. Resultados: Se evaluaron 20 pacientes consecutivos con TAC y RM cardiaca, 18 del sexo masculino, con una edad promedio de 52 ± 15 años. No hubo diferencia significativa entre las mediciones por TAC y por RM cardiaca del volumen telediastólico (VTD) y telesistólico (VTS) del VI, ni en el volumen latido (VL), la masa ventricular izquierda o la fracción de expulsión del VI (FEVI). Conclusión: Los resultados demuestran una alta correlación entre los parámetros de función ventricular sistólica clínicamente relevantes evaluados por TAC y por RM cardiaca. Esto sugiere que puede evaluarse la función ventricular en forma satisfactoria al mismo tiempo que se estudian estructuralmente las coronarias mediante el TCMD-16.

The evaluation of Left ventricular function has both prognostic as well as therapeutic implications in patients with heart disease. Non-invasive coronary angiography with computed tomography using 16 slices (MDCT-16) allows to obtain images of the coronary anatomy due to its high spatial and temporal resolution, and also, to obtain data regarding Left ventricular function. The objective of this study was to correlate the use of MDCT-16 forthe evaluation of the Left ventricular parameters using MRI as the Standard of reference Methods: MRI: Se A 1.5 Tesla GE Cvl Scanner optimized for cardiovascular applications was used. Using an ECG gated steady state fast precession sequence (SSFP, Thickness 10 mm, Flip Angle 45, FOV 36 cm. NEX 1, Frequency 256, Phase 128, Partial FOV 0.75, 16 VPS), 6 to 8 short axis images of from base to apex of the left ventricle were obtained. Tomography: Using a 16 slice Multidetector tomograph (GE Lightspeed) and using ECG synchronization, images of the heart were obtained after the administration of 80 mis. of no-ionic contrast. The images were reconstructed off-line to obtain from 6 to 8 slices in a similar fashion to that of MR. Both studies were independently analyzed by 2 operators who obtained the ventricular function data. Linear correlation and a Paired T Student test was used to analyze the data and was considered significant when p < 0.05. Results: 20 consecutive patients were evaluated with MDCT-16 and MRI, 18 males, mean age 52 ± 15 years. There was no significant difference among the measurements for cardiac CT and MRI of the end-diastolic volume (EDV) and end-sistolic volume (ESV), stroke volume (SV), LV Mass or LV ejection fraction (LVEF). Conclusion: This results show a high correlation among the clinically relevant ventricular function parameters evaluated by cardiovascular CT and MRI. This findings suggest that ventricular function can be successfully evaluated along with the coronary anatomy using MDCT-16.

[Usefulness of transesophageal dobutamine stress echocardiography in the detection of ischemic cardiopathy]. / Utilidad de la ecocardiografía omniplanar transesofágica de stress con dobutamina en la detección de cardiopatía isquémica.

OBJECTIVE: To assess the usefulness of transesophageal dobutamine stress echocardiography (TEDSE), to identify patients with coronary artery disease. METHODS: Patients referred for TEDSE with coronary angiography were included. Images were digitized in systolic cine-loop at baseline, with low dose-dobutamine (14.4 +/- 5 micrograms/kg/min), with high dose-dobutamine (28.7 +/- 10.5 micrograms/kg/min) and during recovery, and then analyzed by two observers. The left ventricle was divided into 16 segments according to coronary distribution, and the study was considered abnormal if there was a new or worsening of the segmental wall motion abnormality. Quantitative coronary angiographies were independently assessed, and lesions considered significant if they had > or = 70% diameter stenosis. RESULTS: Sixty eight patients were included. TEDSE sensitivity, specificity, and accuracy were 93%, 89.7%, and 91.1%, respectively. TEDSE correctly detected 7/7 single vessel disease and 20/22 multiple vessel disease patients. Twelve-lead ECG had a sensitivity, specificity, and accuracy of 38.3%, 91.8%, and 74.5% respectively, to detect the same lesions. CONCLUSIONS: TEDSE is feasible, safe, sensitive, and specific to detect significant coronary lesions. It should be considered in patients with suboptimal acoustic window or poor visualization of endocardial borders.

Utilidad de la ecocardiografía omniplanar transesofßgica de stress con dobutamina en la detección de cardiopatÝa isquÚmica / Usefulness of transesophageal dobutamine stress echocardiography in the detection of ischemic cardiopathy

OBJECTIVE: To assess the usefulness of transesophageal dobutamine stress echocardiography (TEDSE), to identify patients with coronary artery disease. METHODS: Patients referred for TEDSE with coronary angiography were included. Images were digitized in systolic cine-loop at baseline, with low dose-dobutamine (14.4 +/- 5 micrograms/kg/min), with high dose-dobutamine (28.7 +/- 10.5 micrograms/kg/min) and during recovery, and then analyzed by two observers. The left ventricle was divided into 16 segments according to coronary distribution, and the study was considered abnormal if there was a new or worsening of the segmental wall motion abnormality. Quantitative coronary angiographies were independently assessed, and lesions considered significant if they had > or = 70 diameter stenosis. RESULTS: Sixty eight patients were included. TEDSE sensitivity, specificity, and accuracy were 93, 89.7, and 91.1, respectively. TEDSE correctly detected 7/7 single vessel disease and 20/22 multiple vessel disease patients. Twelve-lead ECG had a sensitivity, specificity, and accuracy of 38.3, 91.8, and 74.5 respectively, to detect the same lesions. CONCLUSIONS: TEDSE is feasible, safe, sensitive, and specific to detect significant coronary lesions. It should be considered in patients with suboptimal acoustic window or poor visualization of endocardial borders.

Resultados inmediatos de la angioplastía coronaria percutánea transluminal en el Hospital San José de Monterrey / Early results of transluminal angioplasty at the San José Hospital in Monterrey

Analizamos 69 angioplastías coronarias percutáneas transluminales (ACPT) consecutivas, realizadas a 64 pacientes de enero de 1990 a mayo de 1992. La edad fue de 55 ñ 12 años y 80 por ciento eran varones. Los antecedentes incluían tabaquismo (59 por ciento), hipertensión arterial (32 por ciento), infarto de miocardio antiguo (16 por ciento), diabetes (14 por ciento), ACPT previa (12 por ciento) y cirugía de revascularización miocárdica previa (6 por ciento). El colesterol total era de 238 ñ 75 mg/dl. La mayoría presentaban síndromes coronarios isquémicos agudos representados como angina inestable (n = 31) o como infarto del miocardio reciente (n = 23). Angiográficamente, 52 por ciento tenían estenosis coronaria ò 60 por ciento en 1 vaso, 39 por ciento en dos y 9 por ciento en los tres. La fracción de expulsión del VI era de 55 ñ 11 por ciento y la presión telediastólica del VI de 17 ñ 10 mm Hg y se documentaron anormalidades de la sinergia contráctil en 44 por ciento. Se dilataron 1.4 lesiones/pacientes (límites 1-4) para un total de 100 lesiones. Se redujo la estenosis luminal de 88.5 ñ 1.1 por ciento a 22.6 ñ 2.2 por ciento (p<0.0001). Se obtuvo éxito clínico total en un 85.6 por ciento y éxito clínico parcial en 4.3 por ciento. Se obtuvo una revascularización completa en 62.3 por ciento de los casos e incompleta "adecuada" en 26 por ciento. En 30 por ciento se dilataron lesiones múltiples y en 17 por ciento vasos múltiples. De las 100 lesiones dilatadas, 47 pertenecían al territorio de la descendente anterior (éxito angiográfico 91.5 por ciento), 24 a la circunfleja (éxito angiográfico 95.8 por ciento), 26 a la derecha (éxito antiográfico 88.4 por ciento) y 3 a otras. Hubo 10 por ciento de fracasos y 13 por ciento de complicaciones, de las cuales más de la mitad se resolvieron médicamente, pero hubo necesidad de cirugía de revascularización miocárdica de urgenciaen 4 casos (5.7 por ciento). Un paciente falleció