Efficacy of 4-hour rescue therapeutic plasma exchange in severe septic shock patients.

BACKGROUND: Early intervention for septic shock is crucial to reduce mortality and improve outcome. There is still a great debate over the exact time of therapeutic plasma exchange (TPE) administration in septic shock patients. This study aims to investigate the effect of early initiation (within 4 hours) of TPE in severe septic shock on hemodynamics & outcome. METHODS: We conducted a prospective, before-after case series study on 16 septic shock patients requiring high doses of vasopressors admitted in two ICUs from Cairo, Egypt. All of our patients received TPE within 4 hours of ICU admission. The fresh frozen plasma exchange volume = 1.5 × plasma volume. RESULTS: In the 16 patients included in the study, mean arterial pressure was significantly improved after the initial TPE (p < 0.002) and norepinephrine dose which significantly reduced post TPE (p < 0.001). In addition, norepinephrine dose to mean arterial pressure significantly improved (p < 0.001). There was reduction of a net 6 hours fluid balances following the first TPE were observed in all the patients (p < 0.03) by a mean of 757 ml. Systemic vascular resistance index was markedly improved post-TPE along with statistically improved cardiac index (p < 0.01). Stroke volume variance was also significantly decreased after the TPE sessions (p < 0.01). C-reactive protein significantly improved after TPE (P < 0.01). CONCLUSION: Early initiation of TPE in severe septic shock patients might improve hemodynamic measures.

Coronary Atherosclerotic Plaque Vulnerability Rather than Stenosis Predisposes to Non-ST Elevation Acute Coronary Syndromes.

BACKGROUND: Non-ST elevation acute coronary syndromes (NSTE-ACS) may arise from moderately stenosed atherosclerotic lesions that suddenly undergo transformation to vulnerable plaques complicated by rupture and thrombosis. OBJECTIVE: Assessment and tissue characterization of the coronary atherosclerotic lesions among NSTE-ACS patients compared to those with stable angina. METHODOLOGY: Evaluation of IVUS studies of 312 coronary lesions was done by 2 different experienced IVUS readers, 216 lesions in 66 patients with NSTE-ACS (group I) versus 96 lesions in 50 patients with stable angina (group II). Characterization of coronary plaques structure was done using colored-coded iMap technique. RESULTS: The Syntax score was significantly higher in group I compared to group II (18.7 ± 7.8 vs. 8.07 ± 2.5, p=0.001). Body mass index (BMI) was significantly higher in group II while triglycerides levels were higher in group I (P=0.01 & P=0.04, respectively). History of previous MI and PCI was significantly higher in group I (P=0.016 & P=0.001, respectively). The coronary lesions of NSTE-ACS patients had less vessel area (9.86 ± 3.8 vs 11.36 ± 2.9, p=0.001), stenosis percentage (54.7 ± 14.9% vs 68.6 ± 8.7%, p=0.001), and plaque burden (54.4 ± 14.7 vs 67.8 ± 9.8, p=0.001) with negative remodeling index (0.95 ± 20 vs 1.02 ± 0.14, p=0.008) compared to the stable angina group. On the other hand, they had more lipid content (21.8 ± 7.03% vs 7.26 ± 3.47%, p=0.001), necrotic core (18.08 ± 10.19% vs 15.83 ± 4.9%, p=0.02), and calcifications (10.4 ± 5.2% vs 4.19 ± 3.29%, p=0.001) while less fibrosis (51.67 ± 7.07% vs 70.37 ± 11.7%, p=0.001) compared to the stable angina patients. Syntax score and core composition especially calcification and lipid content were significant predictors to NSTE-ACS. CONCLUSIONS: The vulnerability rather than the stenotic severity is the most important factor that predisposes to non-ST segment elevation acute coronary syndromes. The vulnerability is related to the lesion characteristics especially lipidic core and calcification while lesion fibrosis favours lesion stability.

Intravascular evaluation of coronary atherosclerotic lesions among Egyptian diabetic patients with acute coronary syndromes.

BACKGROUND: Coronary artery disease is one of the main causes of death in diabetes mellitus (DM). Egypt was listed among the world top 10 countries regarding the number of diabetic patients by the International Diabetes Federation (IDF). AIM OF WORK: Assessment of the extent of coronary atherosclerotic disease and lesion tissue characterization among diabetic compared to non-diabetic Egyptian patients. METHODOLOGY: IVUS studies of 272 coronary lesions in 116 patients presented with unstable angina were examined. The patients were divided into two groups: diabetic group (50 patients with 117 lesions) and non-diabetic group (66 patients with 155 lesions). RESULTS: As compared to the non-diabetic group, the diabetic patients were more dyslipidemic (84% vs 39.4%, p = 0.001) with higher total cholesterol level (194.6 ±â€¯35.3 vs 174.4 ±â€¯28.5 mg/dl, p = 0.001) and higher LDL-C (145.3 ±â€¯27.1 vs 123.2 ±â€¯31.4, p = 0.001). Regarding lesions characteristics, the diabetic group had longer lesions (19.4 ±â€¯7.4 vs 16.3 ±â€¯7.9 mm, p = 0.002) with higher plaque burden (60.8 ±â€¯15.3 vs 54.8 ±â€¯14.0, p 0.002) and more area stenosis percentage (60.8 ±â€¯15.6 vs 55.6 ±â€¯14.1, p = 0.008). Structurally, the diabetic group lesions had more lipid content (19.8 ±â€¯8.8 vs 16.8 ±â€¯8.7, p = 0.008) and more necrotic core (17.6 ±â€¯7.4 vs 14.7 ±â€¯4.8, p = 0.008) but less calcification (6.9 ±â€¯3.6 vs 11.8 ±â€¯6.3, p = 0.001). The RI was negative in both groups, 0.95 ±â€¯0.13 in the diabetic group vs 0.98 ±â€¯0.19 in non-diabetic group (p = 0.5). Within the diabetic group lesions, the dyslipidaemic subgroup had more lipid content (23. ±â€¯5.2 vs 14.6 ±â€¯8.6, p = 0.01) but less fibrotic component (48.6 ±â€¯4.7 vs 59.1 ±â€¯13.6%, p = 0.01) and less calcification (10.9 ±â€¯6.8% vs 14.07 ±â€¯3.8%, p = 0.02) as compared to the nondyslipidaemic subgroup. CONCLUSIONS: Diabetic patients with coronary atherosclerosis in Egypt have longer lesions with higher plaque burden and more percent area stenosis with negative remodeling index. The diabetic lesions had more lipid content and more necrotic core but less calcification.

Tissue characterization of non-culprit intermediate coronary lesions in non ST elevation acute coronary syndromes.

BACKGROUND: Disruption of vulnerable plaques is the most common cause of acute coronary syndromes. Intravascular ultrasound facilitates cross-sectional imaging of coronary arteries. We aimed at using IVUS to investigate the morphology and tissue characteristics of atherosclerotic plaques of non-culprit intermediate coronary lesions in non-ST elevation ACS setting. METHODS: IVUS assessment of sixty-one intermediate coronary lesions in twenty-eight patients with the diagnosis of Non ST elevation acute coronary syndromes. Ultrasound signals were obtained by an IVUS system using a 40-MHz catheter. RESULTS: Mean age was 53.2 ± 9.1 years. Males = 20 (71.4%). Smoking in 17 (60.7%), hypertension in 16 (57.1%), Dyslipidemia in 12 (42.9%) and DM in 8 (28.6%). Culprit vessels represent 42% of affected vessels. Sixty-one intermediate lesions were detected. Twenty-nine lesions in culprit vessels and thirty-two lesions in non-culprit vessels with higher lipidic content in lesions of culprit vessels (P < 0.001) while a higher calcific content in lesions of non-culprit vessels (P < 0.001). Higher calcific content of proximal more than distal lesions (P = 0.048). Negative remodeling in 55.7% of lesions. CONCLUSIONS: A higher lipidic content in lesions of culprit vessels, while the lesions of non-culprit vessels were more calcific. Higher calcific content of proximal more than distal lesions was defined as well.