RESUMO
Coronary artery disease (CAD) is the most prevalent cardiovascular disease characterized by atherosclerotic plaque buildup that can lead to partial or full obstruction of blood flow in the coronary arteries. Treatment for CAD involves a combination of lifestyle changes, pharmacologic therapy, and modern revascularization procedures. Beta-adrenoceptor antagonists (or beta-blockers) have been widely used for decades as a key therapy for CAD. In this review, prior studies are examined to better understand beta-adrenoceptor antagonist use in patients with acute coronary syndrome, stable coronary heart disease, and in the perioperative setting. The evidence for the benefit of beta-blocker therapy is well established for patients with acute myocardial infarction, but it diminishes as the time from the index cardiac event elapses. The evidence for benefit in the perioperative setting is not strong.
RESUMO
BACKGROUND: Immune checkpoint inhibitor (ICI)-related cardiotoxicity (iRC) is uncommon but can be fatal. There have been few reports of iRC from a rural cancer population and few data for iRC and inflammatory biomarkers. OBJECTIVES: The purpose of this study was to characterize major adverse cardiac events (MACE) in ICI-treated lung cancer patients based in a rural setting and to assess the utility of C-reactive protein (CRP) and neutrophil-lymphocyte ratio (NLR) in the diagnosis of iRC. METHODS: Patients with lung cancer treated with ICIs at Vidant Medical Center/East Carolina University (VMC/ECU) between 2015 and 2018 were retrospectively identified. MACE included myocarditis, non-ST-segment elevated myocardial infarction (NSTEMI), supraventricular tachycardia (SVT), and pericardial disorders. Medical history, laboratory values, pre-ICI electrocardiography (ECG), and echocardiography results were compared in patients with and without MACE. RESULTS: Among 196 ICI-treated patients, 23 patients (11%) developed MACE at a median of 46 days from the first ICI infusion (interquartile range [IQR]: 17 to 83 days). Patients who developed MACE experienced myocarditis (n = 9), NSTEMI (n = 3), SVT (n = 7), and pericardial disorders (n = 4). Ejection fraction was not significantly different at the time of MACE compared to that at baseline (p = 0.495). Compared to baseline values, NLR (10.9 ± 8.3 vs. 20.7 ± 4.2, respectively; p = 0.032) and CRP (42.1 ± 10.1 mg/l vs. 109.9 ± 15.6 mg/l, respectively; p = 0.010) were significantly elevated at the time of MACE. CONCLUSIONS: NLR and CRP were significantly elevated at the time of MACE compared to baseline values in ICI-treated patients. Larger datasets are needed to validate these findings and identify predictors of MACE that can be used in the diagnosis and management of ICI-related iRC.
RESUMO
BACKGROUND: Due to increased morbidity and mortality, prosthetic valve infective endocarditis (IE) with dehiscence requires urgent intervention. Early identification and therapy may prevent embolization. CASE SUMMARY: A 27-year-old Caucasian woman with a history of hepatitis C, intravenous drug abuse, and tricuspid valve (TV) replacement was admitted for recurrent IE. She was found to have bacteraemia and fungaemia, and empiric antibiotics were initiated. Transthoracic echocardiogram (TTE) revealed a mobile 'mass' on the TV and dehiscence. The patient developed cardiogenic shock and repeat TTE showed a ruptured TV and absence of the 'mass', suspicious of embolization. She underwent emergent surgery with TV replacement using a Biocor valve and retrieval of the old CorMatrix valve found in the right mid pulmonary artery (PA). The patient was successfully weaned off inotropic agents and completed a prolonged course of antibiotics and anti-fungals. DISCUSSION: The multi-disciplinary decision on timing of surgical intervention was challenging, especially due to ongoing mycobacterial infection that increased operative risk. With clinical deterioration, urgent surgery was performed revealing an embolized prosthetic valve in the PA. New surgical options for TV replacement in IE with extracellular-based material have shown promising outcomes with little reported data of long term complications. This case demonstrates a rare occurrence of embolized CorMatrix TV and highlights the challenge in timing of appropriate surgical intervention in a septic patient with thrombocytopenia.