RESUMO
BACKGROUND: Remifentanil, an ultra-short-acting µ-opioid receptor agonist, is commonly used for anesthetic management due to excellent adjustability. Remifentanil is known to cause sinus bradycardia, however, because it has a direct negative chronotropic effect on the cardiac conduction system and there is an indirect negative chronotropic effect via the parasympathetic nervous system. CASE PRESENTATION: An 8-year-old Japanese boy was diagnosed with acute hydrocephalus due to a brain tumor in the fourth ventricle and underwent emergency surgery. Imaging examination showed brainstem compression. Endoscopic third ventriculostomy and ventriculoperitoneal shunt surgery were scheduled. Remifentanil was started during induction of general anesthesia, but electrocardiogram showed sinus bradycardia, then Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was immediately discontinued, and we administered atropine sulfate. Complete atrioventricular block was restored to sinus rhythm. When remifentanil was restarted, however, the electrocardiogram again showed sinus bradycardia, Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was again immediately discontinued, we administered adrenaline, and then complete atrioventricular block was restored to sinus rhythm. Fentanyl was used instead of remifentanil with continuous infusion of dopamine. There has since been no further occurrence of complete atrioventricular block. CONCLUSIONS: This is the first known case of complete atrioventricular block in a pediatric patient with increased intracranial pressure seemingly caused by administration of remifentanil.
Assuntos
Bloqueio Atrioventricular , Hidrocefalia , Remifentanil , Humanos , Masculino , Remifentanil/administração & dosagem , Remifentanil/efeitos adversos , Criança , Bloqueio Atrioventricular/induzido quimicamente , Hidrocefalia/cirurgia , Neoplasias Encefálicas/cirurgia , Anestesia Geral/métodos , Anestesia Geral/efeitos adversos , Piperidinas/efeitos adversos , Piperidinas/administração & dosagem , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/administração & dosagem , Anestésicos Intravenosos/efeitos adversos , Anestésicos Intravenosos/administração & dosagemRESUMO
BACKGROUND: The cardiovascular system is among the least systems affected by immune-related adverse events. We report a rare life-threatening case of pembrolizumab-induced myocarditis with complete atrioventricular block and concomitant myositis in a metastatic bladder cancer patient. CASE PRESENTATION: An 82-year-old Caucasian female with invasive urothelial carcinoma, started on first-line pembrolizumab, was admitted four days after receiving her second dose for severe asthenia, diffuse muscle aches, neck pain, and lethargy. In the emergency department, she had several episodes of bradycardia reaching 40 beats per minute associated with general discomfort and fatigue. Electrocardiography showed a third-degree atrioventricular heart block, while the patient remained normotensive. Cardiac damage parameters were altered with elevated levels of creatine phosphokinase of 8930 U/L, suggestive of immune checkpoint inhibitor-induced myositis, and troponin T of 1.060 ng/mL. Transthoracic echocardiography showed a preserved ejection fraction. Pembrolizumab-induced myocarditis was suspected. Therefore, treatment was initiated with high-dose glucocorticoids for 5 days, followed by a long oral steroid taper. A pacemaker was also implanted. Treatment resulted in the resolution of heart block and a decrease in creatine phosphokinase to the normal range. CONCLUSION: Life-threatening cardiac adverse events in the form of myocarditis may occur with pembrolizumab use, warranting vigilant cardiac monitoring. Troponin monitoring in high-risk patients, along with baseline echocardiography may help identify this complication promptly to prevent life-threatening consequences.
Assuntos
Anticorpos Monoclonais Humanizados , Antineoplásicos Imunológicos , Bloqueio Atrioventricular , Carcinoma de Células de Transição , Miocardite , Miosite , Neoplasias da Bexiga Urinária , Humanos , Feminino , Idoso de 80 Anos ou mais , Miocardite/induzido quimicamente , Neoplasias da Bexiga Urinária/tratamento farmacológico , Bloqueio Atrioventricular/induzido quimicamente , Bloqueio Atrioventricular/complicações , Bloqueio Atrioventricular/tratamento farmacológico , Antineoplásicos Imunológicos/efeitos adversos , Miosite/induzido quimicamente , Miosite/tratamento farmacológico , Creatina QuinaseRESUMO
Current treatments for patients in the active phase of Crohn's disease (CD) include conventional treatments and biological treatments. Infliximab (IFX), a TNF-α antagonist, is recommended to induce remission in patients with moderate-to-severe CD who have not responded to conventional therapy. IFX terminates the inflammatory cascade by inhibiting the nuclear factor-κB (NF-κB), mitogen-activated protein kinase (MAPK), and caspase signaling pathways and increases the apoptosis of activated T cells in inflamed tissues.
Assuntos
Bloqueio Atrioventricular , Doença de Crohn , Humanos , Infliximab/efeitos adversos , Doença de Crohn/induzido quimicamente , Anticorpos Monoclonais/uso terapêutico , Bloqueio Atrioventricular/induzido quimicamente , Fator de Necrose Tumoral alfa , Fármacos Gastrointestinais/efeitos adversos , Resultado do TratamentoRESUMO
AIMS: Adenosine has been tested in several randomized controlled trials (RCTs) to minimize the incidence of coronary microvascular obstruction (CMVO). The aim of this study was to pool all the RCTs comparing intracoronary or intravenous adenosine versus placebo in patients with acute coronary syndrome (ACS) undergoing myocardial revascularization. METHODS AND RESULTS: PubMed and Scopus electronic databases were scanned for eligible studies up to 5th June 2022. A total of 26 RCTs with 5843 patients were included. Efficacy endpoints were major adverse cardiac events (MACE), all-cause death, non-fatal myocardial infarction, and heart failure. Atrioventricular blocks and ventricular fibrillation/sustained ventricular tachycardia (VF/SVT) were the safety endpoints. Myocardial blush grade, thrombolysis in myocardial infarction (TIMI) flow grade, left ventricular ejection fraction (LVEF), infarct size, and ST-segment resolution were also assessed. Adenosine administration was not associated with any clinical benefit in terms of MACE, all-cause death, non-fatal myocardial infarction, and heart failure. However, adenosine was associated with an increased rate of advanced atrioventricular blocks and of VF/SVT in studies with total mean ischaemic time >3 h, compared to placebo. Remarkably, among patients undergoing percutaneous coronary intervention, adenosine was associated with reduced myocardial blush grade 0-1 and TIMI flow grade 0-2, compared to placebo. Furthermore, adenosine did not show favourable effects on LVEF and infarct size. CONCLUSION: Adenosine infusion, as adjunctive therapy in ACS, was associated with an increased risk of advanced atrioventricular blocks and increased rates of adenosine-triggered ventricular arrhythmias in patients with long ischaemic time, without providing any clinical benefit compared to placebo.
Assuntos
Síndrome Coronariana Aguda , Bloqueio Atrioventricular , Insuficiência Cardíaca , Infarto do Miocárdio , Humanos , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/tratamento farmacológico , Adenosina/efeitos adversos , Bloqueio Atrioventricular/induzido quimicamente , Bloqueio Atrioventricular/tratamento farmacológico , Insuficiência Cardíaca/tratamento farmacológico , Infarto do Miocárdio/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto , Vasodilatadores/efeitos adversosRESUMO
AIM: To evaluate the efficiency and safety of adenosine triphosphate (ATP) as a stress agent in a cohort of patients undergoing stress perfusion cardiac magnetic resonance imaging (CMRI). MATERIALS AND METHODS: This retrospective study was conducted between December 2019 and October 2021. The study recruited patients who underwent stress perfusion CMRI using ATP as a vasodilator. Adverse events, such as chest pain, flushing, dyspnoea, headache, and splenic switch-off (SSO) phenomenon, were evaluated in the patients who underwent stress perfusion CMRI. RESULTS: The study included 107 patients (age range: 53 ± 11 years; male:female, 62%:38%). The haemodynamic response (heart rate increased by ≥ 10 beats/min) was quick and observed within 2 minutes of ATP infusion. Scanning was stopped in three patients because of atrioventricular block. CMRI images of seven out of 104 patients were excluded from the final analysis because of inferior quality. During ATP infusion, 37/107 patients (35%) experienced mild adverse events, such as chest pain, flushing, dyspnoea, headache, and atrioventricular block. Myocardial infarction and bronchospasms were not observed during ATP infusion. SSO, a marker of adequate stress, was observed in 91% (94/103) of the patients who underwent stress perfusion CMRI. CONCLUSIONS: As a coronary vasodilator, ATP was safe for stress perfusion CMRI. In addition, the adverse events during ATP infusion were mild, which were relieved within 2 minutes of ATP injection cessation. SSO could serve as an indicator of stress success in ATP stress perfusion CMRI.
Assuntos
Bloqueio Atrioventricular , Imagem de Perfusão do Miocárdio , Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Vasodilatadores/efeitos adversos , Trifosfato de Adenosina , Estudos Retrospectivos , Bloqueio Atrioventricular/induzido quimicamente , Imageamento por Ressonância Magnética , Dor no Peito , Perfusão , Dispneia , Cefaleia/induzido quimicamente , Imagem de Perfusão do Miocárdio/métodosRESUMO
An 82-year-old woman was admitted to our hospital because of dyspnea and bradycardia during exertion. Electrocardiography revealed complete atrioventricular block. During pacemaker implantation, a small dose (12.5 mg) of hydroxyzine was injected for sedation, and torsade de pointes (Tdp) occurred. The QT interval was prolonged after administration of hydroxyzine, and Tdp was observed after the R on T phenomenon occurred, indicating that hydroxyzine was capable of prolonging the QT interval and causing Tdp. Therefore, we must be cautious when administering hydroxyzine for sedation during surgery, especially in patients with bradycardia.
Assuntos
Bloqueio Atrioventricular , Marca-Passo Artificial , Torsades de Pointes , Idoso de 80 Anos ou mais , Bloqueio Atrioventricular/induzido quimicamente , Bloqueio Atrioventricular/diagnóstico , Eletrocardiografia , Feminino , Humanos , Hidroxizina/efeitos adversos , Torsades de Pointes/induzido quimicamente , Torsades de Pointes/diagnóstico , Torsades de Pointes/terapiaRESUMO
[Figure: see text].
Assuntos
Potenciais de Ação , Bloqueio Atrioventricular/metabolismo , Nó Atrioventricular/metabolismo , Canais de Cálcio Tipo L/metabolismo , Frequência Cardíaca , Canais Disparados por Nucleotídeos Cíclicos Ativados por Hiperpolarização/metabolismo , Miócitos Cardíacos/metabolismo , Resistência Física , Animais , Bloqueio Atrioventricular/induzido quimicamente , Bloqueio Atrioventricular/diagnóstico , Bloqueio Atrioventricular/fisiopatologia , Nó Atrioventricular/fisiopatologia , Atropina , Biópsia , Canais de Cálcio Tipo L/genética , Modelos Animais de Doenças , Eletrocardiografia , Cavalos , Canais Disparados por Nucleotídeos Cíclicos Ativados por Hiperpolarização/genética , Masculino , Camundongos Endogâmicos C57BL , MicroRNAs/genética , MicroRNAs/metabolismo , Condicionamento Físico Animal , Propranolol , Natação , Transcrição GênicaRESUMO
Micrurus surinamensis is a coral snake from the Elapidae family of wide distribution in Amazonia Forest. Its venom contains neurotoxins that induce muscular and respiratory paralysis; however, its cardiovascular action is not yet characterized. The aim of this study was to investigate the cardiotoxic effects caused by M. surinamensis poisoning in rodents. Twelve guinea pigs (Cavia porcellus) were distributed in two groups (n = 6) named as control and envenomed. The control group received 0.2 ml of PBS/BSA via intramuscular injection (IM), while envenomed animals received 0.75 µg of venom per g of body weight, also via IM. Electrocardiographic examination (ECG) and biochemical serum tests were conducted before and 2 h after inoculation. ECG of the envenomed animals revealed severe progressive arrhythmias including atrioventricular block, supraventricular, and ventricular extrasystoles. Serum biochemistry showed significant increase in CK, CK-MB, and LDH enzymes corroborating the skeletal and cardiac muscle damage. Myonecrosis and degeneration were observed in both skeletal and heart muscle; nevertheless, transmission electron microscopy revealed cardiac muscle fibers fragmentation. In conclusion, M. surinamensis venom has a potent cardiotoxic activity eliciting arrhythmogenic effects and heart damage after only 2 h of envenomation.
Assuntos
Arritmias Cardíacas/induzido quimicamente , Cobras Corais , Venenos Elapídicos/toxicidade , Animais , Arritmias Cardíacas/fisiopatologia , Complexos Atriais Prematuros/induzido quimicamente , Complexos Atriais Prematuros/fisiopatologia , Bloqueio Atrioventricular/induzido quimicamente , Bloqueio Atrioventricular/fisiopatologia , Cardiotoxicidade , Cobaias , Frequência Cardíaca/efeitos dos fármacos , Masculino , Músculo Esquelético/efeitos dos fármacos , Músculo Esquelético/patologia , Miócitos Cardíacos/efeitos dos fármacos , Miócitos Cardíacos/metabolismo , Miócitos Cardíacos/ultraestrutura , Necrose , Fatores de Tempo , Complexos Ventriculares Prematuros/induzido quimicamente , Complexos Ventriculares Prematuros/fisiopatologiaRESUMO
OBJECTIVE: To report a case of second-degree atrioventricular block associated with concomitant use of aprepitant and amlodipine. CASE: A 73-year-old man with lung cancer was treated with aprepitant for prophylactic use for the prevention of nausea and vomiting, concomitantly with cisplatin, gemcitabine, and an investigational drug (anti-epidermal growth factor receptor monoclonal antibody). He was diagnosed with first-degree atrioventricular block and was taking amlodipine for hypertension. During the first cycle of chemotherapy, 5 days after the start of aprepitant, he experienced Wenckebach second-degree atrioventricular block (Mobitz type I), and amlodipine was discontinued. After day 6, the atrioventricular block was not shown. According to the Naranjo adverse drug reaction scale, a score of 7 was obtained (causality: probable). In addition, using the Drug Interaction Probability Scale, a score of 6 was obtained (causality: probable). CONCLUSION: The drug-drug interaction between aprepitant and amlodipine was considered to have deteriorated his atrioventricular block, conceivably due to the inhibition of cytochrome P450 (CYP) 3A-mediated metabolism of amlodipine by aprepitant.
Assuntos
Antieméticos , Bloqueio Atrioventricular , Neoplasias Pulmonares , Idoso , Anlodipino/efeitos adversos , Aprepitanto/uso terapêutico , Bloqueio Atrioventricular/induzido quimicamente , Humanos , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/tratamento farmacológico , Masculino , Morfolinas/efeitos adversos , VômitoRESUMO
BACKGROUND: Relative contraindications to adenosine use have included heart transplant and dipyridamole. We previously demonstrated the safety and efficacy of adenosine-induced atrioventricular (AV) block in healthy young heart transplant recipients while suspending dipyridamole therapy (dual antiplatelet agent). This prospective follow-up study evaluated the safety and efficacy of adenosine use in the same cohort of heart transplant recipients while on dipyridamole. METHODS: Adenosine was incrementally dosed until AV block occurred (maximum 200 mcg/kg up to 12 mg). The primary outcome was clinically significant asystole (≥12 seconds). Secondary outcomes included maximal adenosine dose, AV block duration, dysrhythmias, and clinical symptoms. Outcomes were compared to the parent study. RESULTS: Thirty of 39 eligible patients (5-24 years) were tested. No patient (0%, CI 0%-8%) experienced clinically significant asystole. AV block occurred in 29/30 patients (97%, CI 86%-100%). The median dose causing AV block was 50mcg/kg (vs 100 mcg/kg off dipyridamole; P = .011). Seventeen patients (57%, CI 39%-72%) required less adenosine to achieve AV block on dipyridamole; six (20%) required more. AV block occurred at doses ≥25 mcg/kg in all patients. In pairwise comparison to prior testing off dipyridamole, no significant change occurred in AV block duration, frequency of cardiac ectopy, or incidence of reported symptoms. No atrial fibrillation/flutter occurred. CONCLUSIONS: AV block often occurs at twofold lower adenosine doses in healthy young heart transplant recipients taking oral dipyridamole, compared with previous testing of this cohort off dipyridamole. Results suggest that initial dosing of 25 mcg/kg (maximum 0.8 mg) with stepwise escalation poses low risk of prolonged asystole on dipyridamole.
Assuntos
Adenosina/administração & dosagem , Antiarrítmicos/administração & dosagem , Bloqueio Atrioventricular/induzido quimicamente , Dipiridamol/administração & dosagem , Transplante de Coração , Complicações Pós-Operatórias/tratamento farmacológico , Taquicardia Supraventricular/tratamento farmacológico , Adenosina/farmacologia , Adenosina/uso terapêutico , Adolescente , Antiarrítmicos/farmacologia , Antiarrítmicos/uso terapêutico , Criança , Pré-Escolar , Dipiridamol/farmacologia , Dipiridamol/uso terapêutico , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Seguimentos , Humanos , Masculino , Estudos Prospectivos , Taquicardia Supraventricular/etiologia , Adulto JovemRESUMO
INTRODUCTION: Immune Checkpoint Inhibitor (ICI) therapy is now a standard of care in numerous cancers with very promising results. Nevertheless, adverse events, and especially immune-related adverse events (irAEs) not reported during clinical trials, are emerging and can be life-threatening. OBSERVATION: We report here a teachable case of a 80 year-old man, of third-degree atrioventricular block consecutive to myocarditis associated with the administration of nivolumab (anti-PD1) monotherapy. CONCLUSION: Myocarditis occurring during ICI treatment is a rare but potentially lethal event. Daily serum troponin level seems to predict ICI-related myocarditis but interpretation could be difficult in the context of associated myositis. Echocardiography and cardiac MRI are also useful but can remain negative. Electrocardiogram is a cornerstone of myocarditis diagnosis. In case of cardiac involvement, continuous heart rhythm monitoring should be performed in addition to the administration of high-dose corticosteroids therapy and the cessation of ICI therapy. Add-on treatments should be discussed with a well-trained multidisciplinary team.
Assuntos
Bloqueio Atrioventricular/induzido quimicamente , Inibidores de Checkpoint Imunológico/efeitos adversos , Miocardite/induzido quimicamente , Nivolumabe/efeitos adversos , Idoso de 80 Anos ou mais , Antineoplásicos Imunológicos/efeitos adversos , Antineoplásicos Imunológicos/uso terapêutico , Bloqueio Atrioventricular/complicações , Bloqueio Atrioventricular/patologia , Carcinoma de Células Escamosas/complicações , Carcinoma de Células Escamosas/tratamento farmacológico , Diabetes Mellitus Tipo 2/complicações , Humanos , Inibidores de Checkpoint Imunológico/uso terapêutico , Imunoterapia/efeitos adversos , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/tratamento farmacológico , Masculino , Miocardite/complicações , Miocardite/patologia , Nivolumabe/uso terapêutico , Receptor de Morte Celular Programada 1/antagonistas & inibidores , Receptor de Morte Celular Programada 1/imunologiaRESUMO
BACKGROUND & AIMS: Etrasimod (APD334) is an oral, selective sphingosine 1-phosphate receptor modulator in development for immune-mediated inflammatory disorders. We assessed the efficacy and safety of etrasimod in patients with moderately to severely active ulcerative colitis (UC). METHODS: In a phase 2, proof-of-concept, double-blind, parallel-group study, adult outpatients with modified Mayo Clinic scores (MCSs) (stool frequency, rectal bleeding, and endoscopy findings) of 4-9, endoscopic subscores of 2 or more, and rectal bleeding subscores of 1 or more were randomly assigned to groups given once-daily etrasimod 1 mg (n = 52), etrasimod 2 mg (n = 50), or placebo (n = 54) for 12 weeks. The study was performed from October 15, 2015, through February 14, 2018, at 87 centers in 17 countries. The primary endpoint was an increase in the mean improvement in modified MCS from baseline to week 12. Secondary endpoints included the proportion of patients with endoscopic improvement (subscores of 1 or less) from baseline to week 12. Exploratory endpoints, including clinical remission, are reported in the article, although the study was statistically powered to draw conclusions only on the primary endpoint. RESULTS: At week 12, the etrasimod 2 mg group met the primary and all secondary endpoints. Etrasimod 2 mg led to a significantly greater increase in mean improvement in modified MCS from baseline than placebo (difference from placebo, 0.99 points; 90% confidence interval, 0.30-1.68; P = .009), and etrasimod 1 mg led to an increase in mean improvement from baseline in modified MCS of 0.43 points more than placebo (90% confidence interval, reduction of 0.24 to increase of 1.11; nominal P = .15). Endoscopic improvement occurred in 41.8% of patients receiving etrasimod 2 mg vs 17.8% receiving placebo (P = .003). Most adverse events were mild to moderate. Three patients had a transient, asymptomatic, low-grade atrioventricular block that resolved spontaneously all patients had evidence of atrioventricular block before etrasimod exposure. CONCLUSIONS: In patients with moderately to severely active ulcerative colitis, etrasimod 2 mg was more effective than placebo in producing clinical and endoscopic improvements. Further clinical development is warranted. Clinicaltrials.gov, Number: NCT02447302.
Assuntos
Acetatos/administração & dosagem , Bloqueio Atrioventricular/epidemiologia , Colite Ulcerativa/tratamento farmacológico , Hemorragia Gastrointestinal/prevenção & controle , Indóis/administração & dosagem , Acetatos/efeitos adversos , Adulto , Doenças Assintomáticas/epidemiologia , Bloqueio Atrioventricular/induzido quimicamente , Colite Ulcerativa/complicações , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/imunologia , Colo/diagnóstico por imagem , Colo/efeitos dos fármacos , Colo/patologia , Colonoscopia , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/etiologia , Humanos , Indóis/efeitos adversos , Quimioterapia de Indução/efeitos adversos , Quimioterapia de Indução/métodos , Mucosa Intestinal/diagnóstico por imagem , Mucosa Intestinal/efeitos dos fármacos , Mucosa Intestinal/patologia , Masculino , Pessoa de Meia-Idade , Placebos/administração & dosagem , Placebos/efeitos adversos , Estudo de Prova de Conceito , Reto , Índice de Gravidade de Doença , Receptores de Esfingosina-1-Fosfato/imunologia , Receptores de Esfingosina-1-Fosfato/metabolismo , Resultado do TratamentoRESUMO
We report a case of a 74-year-old man who developed myocarditis complicated by atrioventricular (AV) block following two doses of nivolumab for the treatment of non-small cell lung cancer. A diagnosis of drug-induced acute myocarditis with complete AV block was considered on the basis of elevated troponin, new onset left ventricular (LV) systolic dysfunction, absence of acute myocardial infarction and some findings suggestive of myocarditis on cardiac magnetic resonance. The patient was commenced on glucocorticoids, perindopril and carvedilol. AV block and LV dysfunction persisted despite 2 weeks of treatment. He ultimately became hypotensive which prompted an implantation of a cardiac resynchronisation therapy pacemaker. Follow-up echocardiogram at 6 weeks showed resolution of LV systolic dysfunction. However, he continued to have AV block.
Assuntos
Antineoplásicos Imunológicos/efeitos adversos , Bloqueio Atrioventricular/induzido quimicamente , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Neoplasias Pulmonares/tratamento farmacológico , Miocardite/induzido quimicamente , Nivolumabe/efeitos adversos , Troponina/efeitos dos fármacos , Idoso , Antineoplásicos Imunológicos/administração & dosagem , Bloqueio Atrioventricular/terapia , Ecocardiografia , Humanos , Masculino , Miocardite/terapia , Nivolumabe/administração & dosagem , Marca-Passo Artificial , Resultado do TratamentoRESUMO
BACKGROUND: Adenosine or regadenoson are often used with pharmacologic stress testing. Adenosine may trigger atrioventricular block (AVB). Despite its higher selectivity, regadenoson has also been associated with AVB. We studied the incidence of de novo AVB with these agents. METHODS: A comprehensive search of SCOPUS was performed from inception to March 2016. Studies of at least 10 patients, using adenosine and/or regadenoson with SPECT-MPI, reporting rates of AVB were selected for further review. RESULTS: Thirty four studies were pooled including 22,957 patients. Adenosine was used in 21 studies and regadenoson in 15. Both were administered in two studies. The estimated incidence of overall and high-grade AVB was 3.81% (95% CI 1.99%-6.19%) and 1.93% (95% CI 0.77%-3.59%), respectively. The incidence of AVB (8.58%; 95% CI 5.55%-12.21% vs 0.30%; 95% CI 0.04%-0.82%, respectively, P < .001) and high-grade AVB (5.21%; 95% CI 2.81%-8.30% vs 0.05%; 95% CI < .001%-0.19% respectively, P < .001) were higher with adenosine compared to regadenoson. CONCLUSION: AVB is seen in about 4% of patients undergoing vasodilator stress test. Both overall and high-grade AVB are more frequent with adenosine compared to regadenoson.
Assuntos
Adenosina/efeitos adversos , Bloqueio Atrioventricular/induzido quimicamente , Doença da Artéria Coronariana/diagnóstico por imagem , Teste de Esforço , Purinas/efeitos adversos , Pirazóis/efeitos adversos , Tomografia Computadorizada de Emissão de Fóton Único , Adenosina/farmacologia , Idoso , Bloqueio Atrioventricular/diagnóstico por imagem , Doença da Artéria Coronariana/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Imagem de Perfusão do Miocárdio , Purinas/farmacologia , Pirazóis/farmacologia , Reprodutibilidade dos Testes , Vasodilatadores/efeitos adversos , Vasodilatadores/farmacologiaRESUMO
Türe M, Bilici M, Akin A, Demir F, Balik H, Darakçi SM. Complete atrioventricular block associated with clozapine intoxication: case report. Turk J Pediatr 2019; 61: 618-621. Clozapine is one of the atypical anti-psychotic drugs used in the treatment of resistant schizophrenia. Although cardiac side-effects are rare, it has been reported that there may be development of myocarditis, dilated cardiomyopathy, postural orthostatic hypotension and prolonged QT duration. Complete atrioventricular (AV) block is characterized by the inability to transmit all of the atrial signal to the ventricles. Causes may be congenital, idiopathic or acquired which are associated with surgery, infection, or muscle disease. AV block is extremely serious and permanent pacemaker insertion is usually necessary for all patients. Complete AV block may develop due to clozapine intoxication through increase in vagal tonus, sinoatrial node (SN) and the inhibition of atrioventricular node signalling. The case presented here is of a 15-year old female patient who developed AV total cardiac block associated with the taking of clozapine in a suicide attempt.
Assuntos
Bloqueio Atrioventricular/induzido quimicamente , Nó Atrioventricular/fisiopatologia , Clozapina/intoxicação , Eletrocardiografia/efeitos dos fármacos , Adolescente , Antipsicóticos/intoxicação , Bloqueio Atrioventricular/fisiopatologia , Bloqueio Atrioventricular/terapia , Nó Atrioventricular/efeitos dos fármacos , Feminino , Humanos , Marca-Passo Artificial , Tentativa de SuicídioRESUMO
A 46-year-old woman with quiescent lupus presented with worsening pleuritic chest pain and dyspnoea. Bedside echocardiogram confirmed large pericardial effusion with cardiac tamponade. Emergency bedside pericardiocentesis was performed. Pericardial fluid cytology confirmed diffuse large B cell lymphoma, stage four on positron emission tomography. Conventional rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone chemotherapy achieved good response in all sites except the pericardium. Progressive cardiac involvement was complicated by atrioventricular conduction block requiring permanent pacemaker. Second-line palliative chemotherapy was performed.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Linfoma não Hodgkin/complicações , Derrame Pericárdico/diagnóstico por imagem , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Bloqueio Atrioventricular/induzido quimicamente , Bloqueio Atrioventricular/terapia , Ecocardiografia/métodos , Evolução Fatal , Feminino , Humanos , Linfoma não Hodgkin/diagnóstico por imagem , Linfoma não Hodgkin/tratamento farmacológico , Linfoma não Hodgkin/patologia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Marca-Passo Artificial/normas , Cuidados Paliativos/métodos , Derrame Pericárdico/citologia , Derrame Pericárdico/etiologia , Derrame Pericárdico/terapia , Pericardiocentese/métodos , Tomografia por Emissão de Pósitrons/métodosRESUMO
Neostigmine is the anticholinesterase drug most commonly used to reverse blockade or speed up recovery from neuromuscular blockade from nondepolarizing neuromuscular blocking drugs. Because of its cardiac muscarinic effects, prior or simultaneous administration of glycopyrrolate or atropine is usually recommended. There have been a few case reports of bradycardia, atrio-ventricular (AV) block, and cardiac arrest following neostigmine/glycopyrrolate administration to reverse neuromuscular block affecting several patients. In this report, we describe a case of 21-year-old with a history of seizure disorder and developmental delay that presented for dental surgery under general anesthesia and developed type I AV block following the simultaneous administration of neostigmine and glycopyrrolate to reverse a nondepolarizing neuromuscular block with rocuronium at the end of his surgery. We suggest that the chronic use of antiepileptic drugs in this patient in combination with neostigmine and glycopyrrolate lead to AV block in this patient. We also review similar cases reported in the literature and suggest an explanation for this observed phenomenon.
Assuntos
Bloqueio Atrioventricular/induzido quimicamente , Nó Atrioventricular/efeitos dos fármacos , Inibidores da Colinesterase/efeitos adversos , Glicopirrolato/administração & dosagem , Frequência Cardíaca/efeitos dos fármacos , Antagonistas Muscarínicos/efeitos adversos , Neostigmina/efeitos adversos , Bloqueio Neuromuscular/métodos , Fármacos Neuromusculares não Despolarizantes/administração & dosagem , Rocurônio/administração & dosagem , Potenciais de Ação/efeitos dos fármacos , Anticonvulsivantes/administração & dosagem , Anticonvulsivantes/efeitos adversos , Bloqueio Atrioventricular/diagnóstico , Bloqueio Atrioventricular/fisiopatologia , Nó Atrioventricular/fisiopatologia , Inibidores da Colinesterase/administração & dosagem , Glicopirrolato/efeitos adversos , Humanos , Masculino , Antagonistas Muscarínicos/administração & dosagem , Neostigmina/administração & dosagem , Fatores de Risco , Adulto JovemRESUMO
Pembrolizumab, a humanized monoclonal IgG4 antibody directed against programmed death-1, is an immune checkpoint inhibitor that has been introduced for the treatment of non-small-cell lung cancer. However, immune checkpoint inhibitors may cause severe immune-related adverse events. We herein present a case of lung cancer with complete atrioventricular block associated with acute myocarditis, which developed 16 days after the administration of pembrolizumab. The clinical course of this case suggested a strong need for close cardiac monitoring when pembrolizumab is administered on an outpatient basis.
Assuntos
Anticorpos Monoclonais Humanizados/efeitos adversos , Antineoplásicos Imunológicos/efeitos adversos , Bloqueio Atrioventricular/induzido quimicamente , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Neoplasias Pulmonares/tratamento farmacológico , Miocardite/induzido quimicamente , Doença Aguda , Idoso , Humanos , Masculino , Monitorização Fisiológica , Receptor de Morte Celular Programada 1/antagonistas & inibidoresRESUMO
BACKGROUND: Supraventricular tachycardia is common after heart transplantation. Adenosine, the standard therapy for treating supraventricular tachycardia in children and adults without transplantation, is relatively contraindicated after transplantation because of a presumed risk of prolonged atrioventricular block in denervated hearts. This study tested whether adenosine caused prolonged asystole after transplantation and if it was effective in blocking atrioventricular nodal conduction in these patients. METHODS: This was a single-center prospective clinical study including healthy heart transplant recipients 6 months to 25 years of age presenting for routine cardiac catheterization during 2015 to 2016. After catheterization, a transvenous pacing catheter was placed and adenosine was given following a dose-escalation protocol until atrioventricular block was achieved. The incidence of clinically significant asystole (≥12 seconds after adenosine) was quantified. The effects of patient characteristics on adenosine dose required to produce atrioventricular block and duration of effect were also measured. RESULTS: Eighty patients completed adenosine testing. No patient (0%; 95% confidence interval, 0-3) required rescue ventricular pacing. Atrioventricular block was observed in 77 patients (96%; 95% confidence interval, 89-99). The median longest atrioventricular block was 1.9 seconds (interquartile range, 1.4-3.2 seconds), with a mean duration of adenosine effect of 4.3±2.0 seconds. No patient characteristic significantly predicted the adenosine dose to produce atrioventricular block or duration of effect. Results were similar across patient weight categories. CONCLUSIONS: Adenosine induces atrioventricular block in healthy pediatric and young adult heart transplant recipients with minimal risk when low initial doses are used (25 µg/kg; 1.5 mg if ≥60 kg) and therapy is gradually escalated. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02462941.