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2.
Lancet ; 396(10253): 759-769, 2020 09 12.
Artigo em Inglês | MEDLINE | ID: mdl-32871100

RESUMO

BACKGROUND: Cardiac muscle hypercontractility is a key pathophysiological abnormality in hypertrophic cardiomyopathy, and a major determinant of dynamic left ventricular outflow tract (LVOT) obstruction. Available pharmacological options for hypertrophic cardiomyopathy are inadequate or poorly tolerated and are not disease-specific. We aimed to assess the efficacy and safety of mavacamten, a first-in-class cardiac myosin inhibitor, in symptomatic obstructive hypertrophic cardiomyopathy. METHODS: In this phase 3, randomised, double-blind, placebo-controlled trial (EXPLORER-HCM) in 68 clinical cardiovascular centres in 13 countries, patients with hypertrophic cardiomyopathy with an LVOT gradient of 50 mm Hg or greater and New York Heart Association (NYHA) class II-III symptoms were assigned (1:1) to receive mavacamten (starting at 5 mg) or placebo for 30 weeks. Visits for assessment of patient status occurred every 2-4 weeks. Serial evaluations included echocardiogram, electrocardiogram, and blood collection for laboratory tests and mavacamten plasma concentration. The primary endpoint was a 1·5 mL/kg per min or greater increase in peak oxygen consumption (pVO2) and at least one NYHA class reduction or a 3·0 mL/kg per min or greater pVO2 increase without NYHA class worsening. Secondary endpoints assessed changes in post-exercise LVOT gradient, pVO2, NYHA class, Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score (KCCQ-CSS), and Hypertrophic Cardiomyopathy Symptom Questionnaire Shortness-of-Breath subscore (HCMSQ-SoB). This study is registered with ClinicalTrials.gov, NCT03470545. FINDINGS: Between May 30, 2018, and July 12, 2019, 429 adults were assessed for eligibility, of whom 251 (59%) were enrolled and randomly assigned to mavacamten (n=123 [49%]) or placebo (n=128 [51%]). 45 (37%) of 123 patients on mavacamten versus 22 (17%) of 128 on placebo met the primary endpoint (difference +19·4%, 95% CI 8·7 to 30·1; p=0·0005). Patients on mavacamten had greater reductions than those on placebo in post-exercise LVOT gradient (-36 mm Hg, 95% CI -43·2 to -28·1; p<0·0001), greater increase in pVO2 (+1·4 mL/kg per min, 0·6 to 2·1; p=0·0006), and improved symptom scores (KCCQ-CSS +9·1, 5·5 to 12·7; HCMSQ-SoB -1·8, -2·4 to -1·2; p<0·0001). 34% more patients in the mavacamten group improved by at least one NYHA class (80 of 123 patients in the mavacamten group vs 40 of 128 patients in the placebo group; 95% CI 22·2 to 45·4; p<0·0001). Safety and tolerability were similar to placebo. Treatment-emergent adverse events were generally mild. One patient died by sudden death in the placebo group. INTERPRETATION: Treatment with mavacamten improved exercise capacity, LVOT obstruction, NYHA functional class, and health status in patients with obstructive hypertrophic cardiomyopathy. The results of this pivotal trial highlight the benefits of disease-specific treatment for this condition. FUNDING: MyoKardia.


Assuntos
Benzilaminas/uso terapêutico , Miosinas Cardíacas/antagonistas & inibidores , Cardiomiopatia Hipertrófica/tratamento farmacológico , Uracila/análogos & derivados , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Benzilaminas/efeitos adversos , Bloqueadores dos Canais de Cálcio/uso terapêutico , Cardiomiopatia Hipertrófica/fisiopatologia , Fármacos Cardiovasculares/uso terapêutico , Método Duplo-Cego , Tolerância ao Exercício/fisiologia , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio/fisiologia , Avaliação de Resultados da Assistência ao Paciente , Uracila/efeitos adversos , Uracila/uso terapêutico
3.
PLoS One ; 15(8): e0237503, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32810154

RESUMO

BACKGROUND: Intraoperative restrictive fluid management strategies might improve postoperative outcomes in liver transplantation. Effects of vasopressors within any hemodynamic management strategy are unclear. METHODS: We conducted an observational cohort study on adult liver transplant recipients between July 2008 and December 2017. We measured the effect of vasopressors infused at admission in the intensive care unit (ICU) and total intraoperative fluid balance. Our primary outcome was 48-hour acute kidney injury (AKI) and our secondary outcomes were 7-day AKI, need for postoperative renal replacement therapy (RRT), time to extubation in the ICU, time to ICU discharge and survival up to 1 year. We fitted models adjusted for confounders using generalized estimating equations or survival models using robust standard errors. We reported results with 95% confidence intervals. RESULTS: We included 532 patients. Vasopressors use was not associated with 48-hour or 7-day AKI but modified the effects of fluid balance on RRT and mortality. A higher fluid balance was associated with a higher need for RRT (OR = 1.52 [1.15, 2.01], p<0.001 for interaction) and lower survival (HR = 1.71 [1.26, 2.34], p<0.01 for interaction) only among patients without vasopressors. In patients with vasopressors, higher doses of vasopressors were associated with a higher mortality (HR = 1.29 [1.13, 1.49] per 10 µg/min of norepinephrine). CONCLUSION: The presence of any vasopressor at the end of surgery was not associated with AKI or RRT. The use of vasopressors might modify the harmful association between fluid balance and other postoperative outcomes. The liberal use of vasopressors to implement a restrictive fluid management strategy deserves further investigation.


Assuntos
Lesão Renal Aguda , Hemodinâmica/fisiologia , Cuidados Intraoperatórios/métodos , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/prevenção & controle , Adulto , Idoso , Estudos de Coortes , Feminino , Hidratação/métodos , Humanos , Transplante de Fígado/métodos , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Quebeque/epidemiologia , Terapia de Substituição Renal/estatística & dados numéricos , Fatores de Risco , Resultado do Tratamento , Equilíbrio Hidroeletrolítico/fisiologia
4.
PLoS Comput Biol ; 16(8): e1008074, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32804929

RESUMO

Congestive heart failure is characterized by suppressed cardiac output and arterial filling pressure, leading to renal retention of salt and water, contributing to further volume overload. Mathematical modeling provides a means to investigate the integrated function and dysfunction of heart and kidney in heart failure. This study updates our previously reported integrated model of cardiac and renal functions to account for the fluid exchange between the blood and interstitium across the capillary membrane, allowing the simulation of edema. A state of heart failure with reduced ejection fraction (HF-rEF) was then produced by altering cardiac parameters reflecting cardiac injury and cardiovascular disease, including heart contractility, myocyte hypertrophy, arterial stiffness, and systemic resistance. After matching baseline characteristics of the SOLVD clinical study, parameters governing rates of cardiac remodeling were calibrated to describe the progression of cardiac hemodynamic variables observed over one year in the placebo arm of the SOLVD clinical study. The model was then validated by reproducing improvements in cardiac function in the enalapril arm of SOLVD. The model was then applied to prospectively predict the response to the sodium-glucose co-transporter 2 (SGLT2) inhibitor dapagliflozin, which has been shown to reduce heart failure events in HF-rEF patients in the recent DAPAHF clinical trial by incompletely understood mechanisms. The simulations predict that dapagliflozin slows cardiac remodeling by reducing preload on the heart, and relieves congestion by clearing interstitial fluid without excessively reducing blood volume. This provides a quantitative mechanistic explanation for the observed benefits of SGLT2i in HF-rEF. The model also provides a tool for further investigation of heart failure drug therapies.


Assuntos
Insuficiência Cardíaca/fisiopatologia , Rim/fisiopatologia , Modelos Cardiovasculares , Volume Sistólico/fisiologia , Compostos Benzidrílicos/uso terapêutico , Cardiomegalia/fisiopatologia , Líquido Extracelular/fisiologia , Glucosídeos/uso terapêutico , Coração/fisiopatologia , Insuficiência Cardíaca/tratamento farmacológico , Hemodinâmica/fisiologia , Humanos , Miócitos Cardíacos/fisiologia , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico
5.
Br J Anaesth ; 125(3): 321-329, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32636084

RESUMO

BACKGROUND: Cardiac cycle efficiency (CCE) derived from a pressure-recording analytical method is a unique parameter to assess haemodynamic performance from an energetic view. This study investigated changes of CCE according to an anatomical diagnosis group, and its association with early postoperative outcomes in children undergoing cardiac surgery. METHODS: Ninety children were included with a ventricular septal defect (VSD; n=30), tetralogy of Fallot (TOF; n=40), or total anomalous pulmonary venous connection (TAPVC; n=20). CCE along with other haemodynamic parameters, was recorded from anaesthesia induction until 48 h post-surgery. Predictive CCE (CCEp) was defined as the average of CCE at post-modified ultrafiltration and CCE at the end of surgery. The relationship between CCE and early outcomes was assessed by the comparison between the high-CCEp group (CCEp ≥75th centile) and the low-CCEp group (CCEp ≤25th centile). RESULTS: There was a significant time × diagnostic group interaction effect in the trend of CCE. Compared with the high-CCEp group (n=23), the low-CCEp group (n=22) required more inotropics post-surgery, had higher lactate concentrations at 8 and 24 h post-surgery, a longer intubation time and longer ICU stay, and higher frequency of peritoneal fluid. CONCLUSIONS: Perioperative changes of CCE vary according to anatomical diagnosis in children undergoing cardiac surgery. Children with TOF have an unfavourable trend of CCE compared with children with VSD or TAPVC. A decline in CCE is associated with adverse early postoperative outcomes. CLINICAL TRIAL REGISTRATION: ChiCTR1800014996.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Cardiopatias Congênitas/cirurgia , Coração/fisiopatologia , Hemodinâmica/fisiologia , Assistência Perioperatória/métodos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Prognóstico , Estudos Prospectivos , Resultado do Tratamento
6.
Br J Anaesth ; 125(2): 122-132, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32711724

RESUMO

BACKGROUND: Despite several clinical trials on haemodynamic therapy, the optimal intraoperative haemodynamic management for high-risk patients undergoing major abdominal surgery remains unclear. We tested the hypothesis that personalised haemodynamic management targeting each individual's baseline cardiac index at rest reduces postoperative morbidity. METHODS: In this single-centre trial, 188 high-risk patients undergoing major abdominal surgery were randomised to either routine management or personalised haemodynamic management requiring clinicians to maintain personal baseline cardiac index (determined at rest preoperatively) using an algorithm that guided intraoperative i.v. fluid and/or dobutamine administration. The primary outcome was a composite of major complications (European Perioperative Clinical Outcome definitions) or death within 30 days of surgery. Secondary outcomes included postoperative morbidity (assessed by a postoperative morbidity survey), hospital length of stay, mortality within 90 days of surgery, and neurocognitive function assessed after postoperative Day 3. RESULTS: The primary outcome occurred in 29.8% (28/94) of patients in the personalised management group, compared with 55.3% (52/94) of patients in the routine management group (relative risk: 0.54, 95% confidence interval [CI]: 0.38 to 0.77; absolute risk reduction: -25.5%, 95% CI: -39.2% to -11.9%; P<0.001). One patient assigned to the personalised management group, compared with five assigned to the routine management group, died within 30 days after surgery (P=0.097). There were no clinically relevant differences between the two groups for secondary outcomes. CONCLUSIONS: In high-risk patients undergoing major abdominal surgery, personalised haemodynamic management reduces a composite outcome of major postoperative complications or death within 30 days after surgery compared with routine care. CLINICAL TRIAL REGISTRATION: NCT02834377.


Assuntos
Abdome/cirurgia , Débito Cardíaco/fisiologia , Hidratação/métodos , Hemodinâmica/fisiologia , Cuidados Intraoperatórios/métodos , Complicações Pós-Operatórias/prevenção & controle , Idoso , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/fisiopatologia , Estudos Prospectivos , Risco
9.
PLoS One ; 15(7): e0235684, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32645710

RESUMO

AIMS: Although patients supported with a Continuous-Flow Left Ventricular Assist Device (CF-LVAD) are hemodynamically stable, their exercise capacity is limited. Hence, the aim of this work was to investigate the underlying factors that lead to peak and submaximal exercise intolerance of CF-LVAD supported patients. METHODS: Seven months after CF-LVAD implantation, eighty three patients performed a maximal cardiopulmonary exercise test and a six minute walk test. Peak oxygen uptake and the distance walked were measured and expressed as a percentage of the predicted value (%VO2p and %6MWD, respectively). Preoperative conditions, echocardiography, laboratory results and pharmacological therapy data were collected and a correlation analysis against %VO2p and %6MWD was performed. RESULTS: CF-LVAD patients showed a relatively higher submaximal exercise capacity (%6MWD = 64±16%) compared to their peak exertion (%VO2p = 51±14%). The variables that correlated with %VO2p were CF-LVAD parameters, chronotropic response, opening of the aortic valve at rest, tricuspid insufficiency, NT-proBNP and the presence of a cardiac implantable electronic device. On the other hand, the variables that correlated with %6MWD were diabetes, creatinine, urea, ventilation efficiency and CF-LVAD pulsatility index. Additionally, both %6MWD and %VO2p were influenced by the CF-LVAD implantation timing, calculated from the occurrence of the cardiac disease. CONCLUSION: Overall, both %6MWD and %VO2p depend on the duration of heart failure prior to CF-LVAD implantation. %6MWD is primarily determined by parameters underlying the patient's general condition, while %VO2p mostly relies on the residual function and chronotropic response of the heart. Moreover, since %VO2p was relatively lower compared to %6MWD, we might infer that CF-LVAD can support submaximal exercise but is not sufficient during peak exertion. Hence concluding that the contribution of the ventricle is crucial in sustaining hemodynamics at peak exercise.


Assuntos
Tolerância ao Exercício/fisiologia , Insuficiência Cardíaca/fisiopatologia , Coração Auxiliar/efeitos adversos , Adulto , Idoso , Ecocardiografia , Exercício Físico/fisiologia , Teste de Esforço , Feminino , Insuficiência Cardíaca/cirurgia , Ventrículos do Coração/fisiopatologia , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio , Função Ventricular Esquerda/fisiologia
10.
Am J Physiol Renal Physiol ; 319(1): F76-F83, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32475131

RESUMO

Acutely increased renal venous pressure (RVP) impairs renal function, but the long-term impact is unknown. We investigated whether chronic RVP elevation impairs baseline renal function and prevents exacerbation of renal dysfunction and cardiovascular instability upon further RVP increase. RVP elevation (20-25 mmHg) or sham operation (sham) was performed in rats. After 1 wk (n = 17) or 3 wk (n = 22), blood pressure, RVP, renal blood flow (RBF), renal vascular conductance (RVC), and glomerular filtration rate (GFR) were measured at baseline and during superimposed RVP increase. Chronic RVP elevation induced extensive renal venous collateral formation. RVP fell to 6 ± 1 mmHg at 1 wk and 3 ± 1 mmHg at 3 wk. Baseline blood pressure and heart rate were unaltered compared with sham. RBF, RVC, and GFR were reduced at 1 wk but normalized by 3 wk. Upon further RVP increase, the drop in mean arterial pressure was attenuated at 3 wk compared with 1 wk (P < 0.05), whereas heart rate fell comparably across all groups; the mean arterial pressure-heart rate relationship was disrupted at 1 and 3 wk. RBF fell to a similar degree as sham at 1 wk (-2.3 ± 0.7 vs. -3.9 ± 1.2 mL/min, P = 0.066); however, at 3 wk, this was attenuated compared with sham (-1.5 ± 0.5 vs. -4.2 ± 0.7 mL/min, P < 0.05). The drop in RVC and GFR was attenuated at 1 and 3 wk (P < 0.05). Thus, chronic RVP elevation induced by partial renal vein ligation elicits extensive renal venous collateral formation, and although baseline renal function is impaired, chronic RVP elevation in this manner induces protective adaptations in kidneys of healthy rats, which attenuates the hemodynamic response to further RVP increase.


Assuntos
Taxa de Filtração Glomerular/fisiologia , Hipertensão Renal/fisiopatologia , Rim/fisiopatologia , Circulação Renal/fisiologia , Veias Renais/fisiopatologia , Animais , Pressão Sanguínea/fisiologia , Frequência Cardíaca/fisiologia , Hemodinâmica/fisiologia , Rim/irrigação sanguínea , Masculino , Ratos , Ratos Endogâmicos Lew
12.
Neurology ; 94(21): e2258-e2269, 2020 05 26.
Artigo em Inglês | MEDLINE | ID: mdl-32366534

RESUMO

OBJECTIVE: To investigate cerebrovascular reactivity (CVR), blood flow, vascular and CSF pulsatility, and their independent relationship with cerebral small vessel disease (SVD) features in patients with minor ischemic stroke and MRI evidence of SVD. METHODS: We recruited patients with minor ischemic stroke and assessed CVR using blood oxygen level-dependent MRI during a hypercapnic challenge, cerebral blood flow (CBF), vascular and CSF pulsatility using phase-contrast MRI, and structural magnetic resonance brain imaging to quantify white matter hyperintensities (WMHs) and perivascular spaces (PVSs). We used multiple regression to identify parameters associated with SVD features, controlling for patient characteristics. RESULTS: Fifty-three of 60 patients completed the study with a full data set (age 68.0% ± 8.8 years, 74% male, 75% hypertensive). After controlling for age, sex, and systolic blood pressure, lower white matter CVR was associated with higher WMH volume (-0.01%/mm Hg per log10 increase in WMH volume, p = 0.02), basal ganglia PVS (-0.01%/mm Hg per point increase in the PVS score, p = 0.02), and higher venous pulsatility (superior sagittal sinus -0.03%/mm Hg, p = 0.02, per unit increase in the pulsatility index) but not with CBF (p = 0.58). Lower foramen magnum CSF stroke volume was associated with worse white matter CVR (0.04%/mm Hg per mL increase in stroke volume, p = 0.04) and more severe basal ganglia PVS (p = 0.09). CONCLUSIONS: Lower CVR, higher venous pulsatility, and lower foramen magnum CSF stroke volume indicate that dynamic vascular dysfunctions underpin PVS dysfunction and WMH development. Further exploration of microvascular dysfunction and CSF dynamics may uncover new mechanisms and intervention targets to reduce SVD lesion development, cognitive decline, and stroke.


Assuntos
Encéfalo/irrigação sanguínea , Doenças de Pequenos Vasos Cerebrais/fisiopatologia , Circulação Cerebrovascular/fisiologia , Hemodinâmica/fisiologia , Idoso , Encéfalo/patologia , Doenças de Pequenos Vasos Cerebrais/complicações , Doenças de Pequenos Vasos Cerebrais/patologia , Líquido Cefalorraquidiano/fisiologia , Feminino , Sistema Glinfático/patologia , Humanos , Imagem por Ressonância Magnética , Masculino , Neuroimagem , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/fisiopatologia , Substância Branca/patologia
13.
BMC Neurol ; 20(1): 189, 2020 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-32414382

RESUMO

BACKGROUND: Endovascular therapy (EVT) is increasingly used to improve cerebral reperfusion after moderate-to-severe acute ischemic stroke (AIS). However, the influence of hemodynamic factors on clinical outcome is still unclear after EVT. Dynamic cerebral autoregulation (dCA) is an important brain reserve mechanism and is impaired after AIS. This study aimed to explore the role of dCA in predicting the outcome of AIS patients after EVT. METHODS: AIS patients with severe stenosis/occlusion of unilateral middle cerebral artery (MCA) or internal carotid and treatment with EVT were enrolled to receive dCA examinations at the 24 h, 72 h and 7th day after stroke onset. Healthy volunteers were also recruited as controls. DCA was recorded from spontaneous fluctuations of blood pressure and MCA flow velocity. Transfer function analysis was used to derive dCA parameters, including phase difference (PD) and coherence in the low-frequency range (0.06-0.12 Hz). The clinical outcome was measured using the modified Rankin Scale (mRS) at 90 days after onset. Multivariate logistic regression was performed to reveal the correlation between dCA and clinical outcomes. The receiver operation characteristics (ROC) curve was performed to determine the cut-off point of PD. RESULTS: A total of 62 AIS patients and 77 healthy controls were included. Compared with controls, dCA were impaired bilaterally till to 7th day after onset in patients, presenting as much lower PD value on the ipsilateral side. During follow-up, we found that PD on the ipsilateral side at 24 h after onset was significantly lower in patients with unfavourable outcome (n = 41) than those with favourable outcome (n = 21), even after adjustment of confounding factors (p = 0.009). ROC curve analysis revealed that PD < 26.93° was an independent predictor of unfavourable-outcome. CONCLUSION: In AIS patients after EVT, dCA was impaired on both sides over the first 7 days. PD on the ipsilateral side at 24 h after onset is an independent unfavourable-outcome predictor for AIS after EVT.


Assuntos
Procedimentos Endovasculares/métodos , Homeostase/fisiologia , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/cirurgia , Adulto , Idoso , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/cirurgia , Circulação Cerebrovascular/fisiologia , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Resultado do Tratamento
14.
Medicine (Baltimore) ; 99(19): e19992, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32384453

RESUMO

The high-sensitivity cardiac troponin I (hs-cTnI) in serum can increase due to an increase in left ventricular (LV) overload in individuals with hypertension. Since LV voltage on an electrocardiogram (ECG) reflects LV load, it is possible that LV voltage is closely associated with hs-cTnI in individuals without hypertension. This study investigated the association between LV voltage indices and serum hs-cTnI levels in normotensive Japanese individuals.Subjects who visited the Enshu Hospital for a health check-up were screened for their eligibility. Subjects with renal dysfunction, cancer, active inflammatory disease, or a history of cardiovascular events were excluded, as were subjects with obvious ST segment or T wave abnormality, Wolff-Parkinson-White syndrome, pacemaker implantation, or frequent arrhythmia in the ECG. Exclusion of individuals with hypertension left 803 subjects (54.8 ±â€Š11.3 years) for final inclusion. The R wave voltage in lead V5 (RV5 voltage), the Sokolow-Lyon voltage (a sum of the QRS wave (a complex wave consists of Q, R, and S wave) of the S wave voltage in lead V1 and the R wave voltage in lead V5), and the Cornell product (a product of QRS duration and QRS voltage) were evaluated by ECG as LV voltage indices. Laboratory measurements included serum hs-cTnI levels. Possible associations between indices of LV voltage on ECG and serum hs-cTnI levels were cross-sectionally investigated in the normotensive subjects.The median values [interquartile range] of hs-cTnI and BNP were and 2.1 [1.4-3.0] and 13.8 [7.7-24.9] pg/mL, respectively. Multivariate regression analysis identified that the levels of hs-cTnI, but not BNP, were significantly associated with RV5 voltage (ß 0.090, P = .0087), Sokolow-Lyon voltage (ß 0.112, P = .0009), and Cornell product (ß 0.101, P = .039) after adjustment for possible confounding factors. Moreover, the RV5 voltage, Sokolow-Lyon voltage, and Cornell product were significantly associated with the hs-cTnI levels after adjustment for possible confounding factors including ECG findings (ß 0.109, P = .0075; ß 0.125, P = .0010; and ß 0.096, P = .0116, respectively).Indices of LV voltage in ECG had close associations with serum hs-cTnI levels in normotensive subjects. These findings support that the ECG findings of LV voltage have significant associations with slight myocardial micro-damage even in normotensive subjects.


Assuntos
Eletrocardiografia/métodos , Ventrículos do Coração , Miocárdio/metabolismo , Troponina I/sangue , Pressão Sanguínea/fisiologia , Correlação de Dados , Feminino , Ventrículos do Coração/metabolismo , Ventrículos do Coração/fisiopatologia , Hemodinâmica/fisiologia , Humanos , Hipertensão/sangue , Hipertensão/fisiopatologia , Japão , Masculino , Pessoa de Meia-Idade
15.
Am Surg ; 86(3): 190-194, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-32223796

RESUMO

Resuscitation of critically ill trauma patients can be precarious, and errors can cause acute kidney injuries. If renal failure develops, continuous renal replacement therapy (CRRT) may be necessary, but adds expense. Hemodynamic transesophageal echocardiography (hTEE) provides objective data to guide resuscitation. We hypothesized that hTEE use improved acute kidney injury (AKI) management, reserved CRRT use for more severe AKIs, and decreased cost and resource utilization. We retrospectively reviewed 2413 trauma patients admitted to a Level I trauma center's ICU between 2009 and 2015. Twenty-three patients required CRRT before standard hTEE use and 11 required CRRT after; these are the "CRRT" and "CRRT/hTEE" groups, respectively. The hTEE group comprised 83 patients evaluated with hTEE, with AKI managed without CRRT. We compared the average creatinine, change in creatinine, and Acute Kidney Injury Network (AKIN) of "CRRT" with "CRRT/hTEE" and "hTEE." We also analyzed several quality measures including ICU length of stay and cost. "CRRT" had a lower AKIN score (1.6) than "CRRT/hTEE" (2.9) (P = 0.0003). "hTEE" had an AKIN score of 2.1 (P = 0.0387). "CRRT" also had increased ICU days (25.1) compared with "CRRT/hTEE" (20.2) (P = 0.014) and "hTEE" (16.8) (P = 0.003). "CRRT" accrued on average $198,695.81 per patient compared with "CRRT/hTEE" ($167,534.19) and "hTEE" ($53,929.01). hTEE provides valuable information to tailor resuscitation. At our institution, hTEE utilization reserved CRRT for worse AKIs and decreased hospital costs.


Assuntos
Lesão Renal Aguda/terapia , Terapia de Substituição Renal Contínua/métodos , Ecocardiografia Transesofagiana/métodos , Hemodinâmica/fisiologia , Mortalidade Hospitalar/tendências , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/mortalidade , Idoso , Reanimação Cardiopulmonar/métodos , Estado Terminal/mortalidade , Estado Terminal/terapia , Feminino , Seguimentos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Centros de Traumatologia , Resultado do Tratamento
16.
Radiology ; 295(3): 722-729, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32228297

RESUMO

Background Despite known limitations, the decision to operate on abdominal aortic aneurysm (AAA) is primarily on the basis of measurement of maximal aneurysm diameter. Purpose To identify volumetric and computational fluid dynamics parameters to predict AAAs that are likely to progress in size. Materials and Methods This study, part of a multicenter prospective registry (NCT01599533), included 126 patients with AAA. Patients were sorted into stable (≤10-mL increase in aneurysm volume) and progression (>10-mL increase in aneurysm volume) groups. Initial AAA characteristics of the derivation cohort were analyzed (maximal diameter and surface, thrombus and lumen volumes, maximal wall pressure, and wall shear stress [WSS]) to identify relevant parameters for a logistic regression model. Model and maximal diameter diagnostic performances were assessed in both cohorts and for AAAs smaller than 50 mm by using area under the receiver operating characteristic curve (AUC). Results Eighty-one patients were included (mean age, 73 years ± 7 years [standard deviation]; 78 men). The derivation and validation cohorts included, respectively, 50 and 31 participants. In the derivation cohort, there was higher mean lumen volume and lower mean WSS in the progression group compared with the stable group (60 mL ± 14 vs 46 mL ± 18 [P = .005] and 66% ± 6 vs 53% ± 9 [P = .02], respectively). Mean lumen volume and mean WSS at baseline were correlated to total volume growth (r = 0.47 [P = .002] and -0.42 [P = .006], respectively). In the derivation cohort, a regression model including lumen volume and WSS to predict aneurysm enlargement was superior to maximal diameter alone (AUC, 0.78 vs 0.52, respectively; P = .003); although no difference was found in the validation cohort (AUC, 0.79 vs 0.71, respectively; P = .51). For AAAs smaller than 50 mm, a regression model that included both baseline WSS and lumen volume performed better than maximal diameter (AUC, 0.79 vs 0.53, respectively; P = .01). Conclusion Combined analysis of lumen volume and wall shear stress was associated with enlargement of abdominal aortic aneurysms at 1 year, particularly in aneurysms smaller than 50 mm in diameter. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Mitsouras and Leach in this issue.


Assuntos
Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Tomografia Computadorizada de Feixe Cônico/métodos , Hemodinâmica/fisiologia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/cirurgia , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Sensibilidade e Especificidade , Trombose/diagnóstico por imagem
17.
Hosp Pract (1995) ; 48(3): 113-118, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32252568

RESUMO

OBJECTIVES: Cardiovascular diseases (CVDs) still remain the main causes of death and disability in the US and worldwide, and the prediction for their future incidence is not well established. The utilization of the new cardiovascular risk score (CVRS) developed by the new ACC/AHA blood pressure treatment guidelines has improved the 10-year prediction of CVDs. However, its predictive value could be further increased with the addition of other risk factors identified with the use of several noninvasive vascular tests. These tests include, the older tests such as flow-mediated dilation (FMD), pulse wave velocity (PWV), pulse pressure (PP), and the newly developed noninvasive vascular tests of, reactive hyperemia-peripheral arterial tonometry (RH-PAT), cardio-ankle vascular index (CAVI), and the inter-arm/inter-leg pressure difference (IAPD/ILPD). METHODS: In order to get a current perspective regarding the usefulness of these new noninvasive vascular tests for the future prediction of CVDs, a Medline search of the English language literature was conducted between 2014 and 2019 using the terms cardiovascular disease, coronary heart disease, noninvasive vascular tests, risk factors, and 26 pertinent papers were retrieved. RESULTS: The analysis of results from these papers showed that these noninvasive vascular tests have an independent predictive value for the future incidence of CVDs and hypertension. However, their long-term predictive value is not well established, since there are no currently, available data from long-term clinical outcome studies. CONCLUSION: The analysis of data from the retrieved papers demonstrated that the new noninvasive vascular tests have an independent predictive value for the future incidence of CVDs and hypertension. However, their long-term predictive value is not established as yet for the lack of long-term outcome studies. When the currently ongoing long-term trials are completed, it is quite possible that the data from these tests added to CVRS could enhance its predictive value.


Assuntos
Doenças Cardiovasculares/epidemiologia , Hemodinâmica/fisiologia , Fatores Etários , Pressão Sanguínea , Comorbidade , Grupos de Populações Continentais , Indicadores Básicos de Saúde , Humanos , Lipídeos/sangue , Valor Preditivo dos Testes , Prognóstico , Análise de Onda de Pulso , Fatores de Risco , Fatores Sexuais
18.
Georgian Med News ; (299): 61-65, 2020 Feb.
Artigo em Russo | MEDLINE | ID: mdl-32242846

RESUMO

The aim of our study was to study and analyze the electrophysiological indicators of rhythm disturbances in heart failure in elderly people who participated in the elimination of the consequences of the Chernobyl accident in the distant period. In order to assess the functional features, 50 elderly patients (65-74 years old) who participated in the liquidation of the consequences of the Chernobyl accident were examined. Patients were divided into 4 groups depending on the length of stay in an environmentally disadvantaged zone: group 1 (April-June 1986) - 8 (16%) people; 2 (June-December 1986) -14 (28%); 3 (1987-1989) -17 (34%) and group 4 (1990-91gg) -11 (22%) people. All patients were on basic therapy. To study cardiogemodynamics in this category of patients, the following electrophysiological research methods were performed: ECG, XM ECG, SMAD, EchoCG. When analyzing electrophysiological studies, the MSExcel and Statistica programs were used. The examined patients showed a high incidence of left ventricular hypertrophy and cardiac arrhythmias. So in the 1st and 2nd groups, atrial fibrillation, sinus tachy and bradycardia, AV blockade of 1-2 degrees were reliably detected. In groups 3 and 4, left ventricular hypertrophy and arrhythmias were detected with a lower frequency. It should be noted that these changes were observed in individuals participating in the LPA from April to December 1986, i.e. in the first year after the accident. According to echocardiography, diastolic dysfunction of the left ventricle was found mainly in individuals of 1-2 groups. High high indices of KDR, BWW and KSO in 1-2 groups are noted. LVMI exceeds its norm in all studied groups. Thus, statistically significant differences of some indicators are revealed with electrophysiological research methods in all groups of elderly patients with heart failure participating in the liquidation of the Chernobyl accident, as well as the high incidence of rhythm disturbances in patients with Chernobyl nuclear power plants.


Assuntos
Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Cardiomiopatias , Técnicas Eletrofisiológicas Cardíacas/métodos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Hemodinâmica/fisiologia , Idoso , Fibrilação Atrial/complicações , Doença Crônica , Ecocardiografia , Eletrocardiografia , Eletrofisiologia , Feminino , Insuficiência Cardíaca/complicações , Testes de Função Cardíaca , Humanos , Hipertrofia Ventricular Esquerda , Masculino , Resultado do Tratamento
19.
Invest Ophthalmol Vis Sci ; 61(4): 3, 2020 04 09.
Artigo em Inglês | MEDLINE | ID: mdl-32271886

RESUMO

Purpose: We developed a combined biomechanical and hemodynamic model of the human eye to estimate blood flow and oxygen concentration within the lamina cribrosa (LC) and rank the factors that influence LC oxygen concentration. Methods: We generated 5000 finite-element eye models with detailed microcapillary networks of the LC and computed the oxygen concentration of the lamina retinal ganglion cell axons. For each model, we varied the intraocular pressure (IOP) from 10 mm Hg to 55 mm Hg in 5-mm Hg increments, the cerebrospinal fluid pressure (13 ± 2 mm Hg), cup depth (0.2 ± 0.1 mm), scleral stiffness (±20% of the mean values), LC stiffness (0.41 ± 0.2 MPa), LC radius (1.2 ± 0.12 mm), average LC pore size (5400 ± 2400 µm2), the microcapillary arrangement (radial, isotropic, or circumferential), and perfusion pressure (50 ± 9 mm Hg). Blood flow was assumed to originate from the LC periphery and drain via the central retinal vein. Finally, we performed linear regressions to rank the influence of each factor on the LC tissue oxygen concentration. Results: LC radius and perfusion pressure were the most important factors in influencing the oxygen concentration of the LC. IOP was another important parameter, and eyes with higher IOP had higher compressive strain and slightly lower oxygen concentration. In general, superior-inferior regions of the LC had significantly lower oxygen concentration than the nasal-temporal regions, resulting in an hourglass pattern of oxygen deficiency. Conclusions: To the best of our knowledge, this study is the first to implement a comprehensive hemodynamical model of the eye that accounts for the biomechanical forces and morphological parameters of the LC. The results provide further insight into the possible relationship of biomechanical and vascular pathways leading to ischemia-induced optic neuropathy.


Assuntos
Velocidade do Fluxo Sanguíneo/fisiologia , Disco Óptico/irrigação sanguínea , Oxigênio/sangue , Fluxo Sanguíneo Regional/fisiologia , Células Ganglionares da Retina/metabolismo , Axônios/metabolismo , Fenômenos Biomecânicos/fisiologia , Simulação por Computador , Análise de Elementos Finitos , Hemodinâmica/fisiologia , Humanos , Pressão Intraocular/fisiologia , Consumo de Oxigênio/fisiologia , Esclera/metabolismo , Estresse Mecânico
20.
Medicine (Baltimore) ; 99(17): e19599, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32332606

RESUMO

BACKGROUND: Epicardial radiofrequency ablation for stand-alone atrial fibrillation under total video-assisted thoracoscopy has gained popularity in recent years. However, severe cardiopulmonary disturbances during the surgery may affect cerebral perfusion and oxygenation. We therefore hypothesized that regional cerebral oxygen saturation (rSO2) would decrease significantly during the surgery. In addition, the influencing factors of rSO2 would be investigated. METHODS: A total of 60 patients scheduled for selective totally thoracoscopic ablation for stand-alone atrial fibrillation were enrolled in this prospective observational study. The rSO2 was monitored at baseline (T0), 15 min after anesthesia induction (T1), 15 minute after 1-lung ventilation (T2), after right pulmonary vein ablation (T3), after left pulmonary vein ablation (T4) and 15 minute after 2-lung ventilation (T5) using a near-infrared reflectance spectroscopy -based cerebral oximeter. Arterial blood gas was analyzed using an ABL 825 hemoximeter. Associations between rSO2 and hemodynamic or blood gas parameters were determined with univariate and multivariate linear regression analyses. RESULTS: The rSO2 decreased greatly from baseline 65.4% to 56.5% at T3 (P < .001). Univariate analyses showed that rSO2 correlated significantly with heart rate (r = -0.173, P = .186), mean arterial pressure (MAP, r = 0.306, P = .018), central venous pressure (r = 0.261, P = .044), arterial carbon dioxide tension (r = -0.336, P = .009), arterial oxygen pressure (PaO2, r = 0.522, P < .001), and base excess (BE, r = 0.316, P = .014). Multivariate linear regression analyses further showed that it correlated positively with PaO2 (ß = 0.456, P < .001), MAP (ß = 0.251, P = .020), and BE (ß = 0.332, P = .003). CONCLUSION: Totally thoracoscopic ablation for atrial fibrillation caused a significant decrease in rSO2. There were positive correlations between rSO2 and PaO2, MAP, and BE.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Circulação Cerebrovascular/fisiologia , Oxigênio/sangue , Cirurgia Torácica Vídeoassistida/métodos , Idoso , Ablação por Cateter/efeitos adversos , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Oximetria , Estudos Prospectivos , Espectroscopia de Luz Próxima ao Infravermelho , Cirurgia Torácica Vídeoassistida/efeitos adversos
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