Simultaneous Pulmonary Artery Pressure and Left Ventricle Stroke Volume Assessment Predicts Adverse Events in Patients With Pulmonary Embolism.

Background Certain echocardiographic parameters may serve as early predictors of adverse events in patients with hemodynamically compromising pulmonary embolism (PE). Methods and Results An observational analysis was conducted for patients with acute pulmonary embolism evaluated by a Pulmonary Embolism Response Team (PERT) between 2014 and 2020. The performance of clinical prediction algorithms including the Pulmonary Embolism Severity Index and Carl Bova score were compared using a ratio of right ventricle and left ventricle hemodynamics by dividing the pulmonary artery systolic pressure by the left ventricle stroke volume. The primary outcome of in-hospital mortality, cardiac arrest, and the need for advanced therapies was evaluated by univariate and multivariable analyses. Of the 343 patients meeting the inclusion criteria, 215 had complete data. Pulmonary artery systolic pressure/left ventricle stroke volume was a clear predictor of the primary end point (odds ratio [OR], 2.31; P=0.005), performing as well or better than the Pulmonary Embolism Severity Index (OR, 1.43; P=0.06) or the Bova score (OR, 1.28; P=0.01). Conclusions This study is the first study to demonstrate the utility of early pulmonary artery systolic pressure/left ventricle stroke volume in predicting adverse clinical events in patients with acute pulmonary embolism. Pulmonary artery systolic pressure/left ventricle stroke volume may be a surrogate marker of ventricular asynchrony in high-risk pulmonary embolism and should be prognostically evaluated.

Implementation of a Standardized Transfusion Protocol for Cardiac Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation Is Associated With Decreased Blood Component Utilization and May Improve Clinical Outcome.

BACKGROUND: Extracorporeal membrane oxygenation supplies oxygenated blood to the body supporting the heart and lungs. Survival rates of 20% to 50% are reported among patients receiving ECMO for cardiac arrest, severe cardiogenic shock, or failure to wean from cardiopulmonary bypass following cardiac surgery. Bleeding is one of the most common complications in ECMO patients due to coagulopathy, systemic anticoagulation, and the presence of large bore cannulas at systemic pressure. Absence of a standardized transfusion protocol in this population leads to inconsistent transfusion practices. Here, we assess a newly developed dedicated transfusion protocol in this clinical setting. METHODS: Data were retrospectively reviewed for the first 30 consecutive cardiac ECMO patients prior and post implementation of the ECMO transfusion protocol. Diagnoses, laboratory results, blood component utilization, and outcomes were collected and analyzed. RESULTS: Comorbidities were similar between the 2 eras, as well as the pre-ECMO ejection fraction (P = .568) and duration on ECMO (P = .278). Transfusion utilization data revealed statistically significant decreases in almost all blood components and a savings in blood component acquisition costs of 51% ($175, 970). In addition, an almost 2-fold increase in survival rate was observed in the post-ECMO transfusion protocol era (63% vs 33%; relative risk = 1.82; 95% confidence interval, 1.07-3.10; P = .028). CONCLUSIONS: Our data indicate that implementation of a standardized transfusion protocol, using more restrictive transfusion indications in cardiac ECMO patients, was associated with reduced blood product utilization, decreased complications, and improved survival. This multidepartmental approach facilitates better communication and adherence to consensus clinical decision making between intensive care unit, surgery, and transfusion service and optimizes care of complicated and acutely ill patients.

Clinical predictors of survival in patients treated with therapeutic hypothermia following cardiac arrest.

INTRODUCTION: Therapeutic hypothermia has been shown to provide neuroprotection and improved survival in patients suffering a cardiac arrest. We report outcomes of consecutive patients receiving therapeutic hypothermia for cardiac arrest and describe predictors of short and long-term survival. METHODS: Eighty patients receiving therapeutic hypothermia between January 2005 and December 2008 were identified and categorized as those who survived and died. Outcomes and predictors of survival were determined. RESULTS: Forty-five patients (56%) survived to hospital discharge and were alive at 30 days and among survivors 41 (91%) were alive 1 year after discharge. Survivors were younger, were more likely to present with VF, required less epinephrine during resuscitation, were more likely to have preserved renal function, and were less likely to be taking beta-blockers and ACE inhibitors. Predictors of survival included VF on presentation (OR 14.9, CI 2.7-83.2, p=0.002), pre-cardiac arrest aspirin use (OR 9.7, CI 1.6-61.1, p=0.02), return of spontaneous circulation <20 min (OR 9.4, CI 2.2-41.1, p=0.003), absence of coronary artery disease (OR 5.3, CI 1.1-24.7, p=0.002) and preserved renal function. CONCLUSION: Therapeutic hypothermia is useful in the treatment of patients suffering a cardiac arrest. Several clinical factors may aid in predicting patients who are likely to survive after a cardiac arrest.

Effect of inhaled carbon ultrafine particles on reactive hyperemia in healthy human subjects.

BACKGROUND: Ultrafine particles (UFP) may contribute to the cardiovascular effects of exposure to particulate air pollution, partly because of their relatively efficient alveolar deposition and potential to enter the pulmonary vascular space. OBJECTIVES: This study tested the hypothesis that inhalation of elemental carbon UFP alters systemic vascular function. METHODS: Sixteen healthy subjects (mean age, 26.9 +/- 6.5 years) inhaled air or 50 microg/m3 elemental carbon UFP by mouthpiece for 2 hr, while exercising intermittently. Measurements at preexposure baseline, 0 hr (immediately after exposure), 3.5 hr, 21 hr, and 45 hr included vital signs, venous occlusion plethysmography and reactive hyperemia of the forearm, and venous plasma nitrate and nitrite levels. RESULTS: Peak forearm blood flow after ischemia increased 3.5 hr after exposure to air but not UFP (change from preexposure baseline, air: 9.31 +/- 3.41; UFP: 1.09 +/- 2.55 mL/min/100 mL; t-test, p = 0.03). Blood pressure did not change, so minimal resistance after ischemia (mean blood pressure divided by forearm blood flow) decreased with air, but not UFP [change from preexposure baseline, air: -0.48 +/- 0.21; UFP: 0.07 +/- 0.19 mmHg/mL/min; analysis of variance (ANOVA), p = 0.024]. There was no UFP effect on pre-ischemia forearm blood flow or resistance, or on total forearm blood flow after ischemia. Venous nitrate levels were significantly lower after exposure to carbon UFP compared with air (ANOVA, p = 0.038). There were no differences in venous nitrite levels. CONCLUSIONS: Inhalation of 50 microg/m3 carbon UFP during intermittent exercise impairs peak forearm blood flow during reactive hyperemia in healthy human subjects.

Skeletal muscle gene expression profiles in 20-29 year old and 65-71 year old women.

Gene expression profiling may provide leads for investigations of the molecular basis of functional declines associated with aging. In this study, high-density oligonucleotide arrays were used to probe the patterns of gene expression in skeletal muscle of seven young women (20-29 years old) and eight healthy older women (65-71 years old). The older subjects had reduced muscle mass, strength, and peak oxygen consumption relative to young women. There were approximately 1000 probe sets that suggested differential gene expression in younger and older muscle according to statistical criteria. The most highly overexpressed genes (>3-fold) in older muscle were p21 (cyclin-dependent kinase inhibitor 1A), which might reflect increased DNA damage, perinatal myosin heavy chain, which might reflect increased muscle fiber regeneration, and tomoregulin, which does not have a defined function in muscle. More than 40 genes encoding proteins that bind to pre-mRNAs or mRNAs were expressed at higher levels in older muscle. More than 100 genes involved in energy metabolism were expressed at lower levels in older muscle. In general, these results support previous observations on the differences in gene expression profiles between younger and older men.

Gene expression profile of aging in human muscle.

Studies of gene expression related to aging of skeletal muscle have included few subjects or a limited number of genes. We conducted the present study to produce more comprehensive gene expression profiles. RNA was extracted from vastus lateralis biopsies obtained from healthy young (21-27 yr old, n = 8) and older men (67-75 yr old, n = 8) and was analyzed with high-density oligonucleotide arrays. Of the approximately 44,000 probe sets on the arrays, approximately 18,000 yielded adequate signals for statistical analysis. There were approximately 700 probe sets for which t-tests or rank sum tests indicated a difference (P

Reduced amount of mitochondrial DNA in aged human muscle.

Muscle concentrations of mRNAs encoded by mitochondrial DNA (mtDNA) decline with aging. To determine whether this can be explained by diminished mtDNA levels, we measured the relative concentrations of mtDNA and a representative mtDNA transcript [encoding cytochrome-c oxidase, subunit 2 (COX-2)] in muscle of young (21-27 yr) and older subjects (65-75 yr). The amount of COX-2 mRNA (relative to 28S rRNA) was 22% lower (P = 0.04) in older muscle, and the amount of mtDNA (relative to nuclear DNA) was 38% lower (P = 0.0002). The average level of mitochondrial transcription factor A (Tfam), a protein essential for mtDNA replication, was similar in younger and older muscle. Tfam mRNA, nuclear respiratory factor-1 mRNA, and several mRNAs encoding proteins required for mtDNA replication were expressed at similar levels in younger and older muscle. The mtDNA concentrations were only weakly related to age-adjusted aerobic fitness (maximal oxygen consumption) and self-reported physical activity levels. We conclude that the lower concentration of mitochondrial mRNAs in older muscle can be explained by a reduced concentration of mtDNA.

Perception of risk for coronary heart disease in women undergoing coronary angiography.

BACKGROUND: Even though coronary heart disease (CHD) is the leading cause of death among women in the United States, most women underestimate their risk of developing CHD. DESIGN: Survey to examine the relationship between women's recollection of being told they were at risk for CHD and the presence of risk factors. SETTING/PARTICIPANTS: A convenience sample of 450 women undergoing coronary angiography at 1 university hospital. MAIN OUTCOME MEASURES: Self-recollection of being told one was at risk for CHD and presence of CHD risk factors. RESULTS: Most women (83.6%) had 3 or more risk factors, 12.2% had 1 or 2 risk factors, and 0.9% had no risk factors. Only 35% of women recalled being told that they were at risk for CHD. Few relationships were found between being told one was at risk for CHD and the presence of individual risk factors. No difference was found in the mean number of risk factors among women who did and did not recall being told they were at risk. In logistic regression analysis, only 5% of the variance in recollection of being told one was at risk was predicted, with only age, education, and having a high cholesterol level significantly contributing to the equation. CONCLUSIONS: Even though women may not remember conversations with their health care provider about CHD risk, the possibility that risk factors were not adequately assessed cannot be discounted. Patient-provider conversations about CHD risk factors should be encouraged as the first step toward successful risk reduction.