Colchicine usage for prevention of post atrial fibrillation ablation pericarditis in patients undergoing high-power short-duration ablation.

INTRODUCTION: Radiofrequency ablation (RFA) for atrial fibrillation (AF) has been associated with variable incidence (0.88%-10%) of pericarditis manifested as chest pain, possibly more prevalent with the advent of high-power short-duration (HPSD) ablation. This has led to the widespread use of colchicine in preventative protocols for postablation pericarditis. However, the efficacy of preventative colchicine has not been validated yet. OBJECTIVE: To evaluate the efficacy of a routine postoperative colchicine regimen (0.6 mg twice a day for 14 days post-AF ablation) for prevention of postablation pericarditis in patients undergoing HPSD ablation. METHOD: We retrospectively evaluated consecutive single-operator HPSD AF ablation procedures at our institution from June 2019 to July 2022. A colchicine protocol was introduced in June 2021 for the prevention of postablation pericarditis. All ablations were performed with 50 watts. Patients were divided into colchicine and noncolchicine groups. We recorded incidence of postablation chest pain, emergency room (ER) visit for chest pain, pericardial effusion, pericardiocentesis, any ER visit, hospitalization, AF recurrence, and cardioversion for AF within the first 30 days following ablation. We also recorded colchicine-related side effects and medication compliance. RESULTS: Two hundred and ninety-four consecutive HPSD AF ablation patients were screened for the study. After implementing the prespecified exclusion criteria, a total of 205 patients were included in the final analysis, yielding 101 patients in the colchicine group and 104 patients in the noncolchicine group. Both groups were well-matched for demographic and procedural parameters. There was no significant difference in postablation chest pain (9.9% vs. 8.6%, p = .7), pericardial effusion (2.9% vs. 0.9%, p = .1), ER visits (11.9% vs. 12.5%, p = .2), 30-day hospitalization for AF recurrence (0.9% vs. 0.96%, p = .3), and 30-day need for cardioversion for AF (3.9% vs. 5.7%, p = .2). Fifteen (15) patients had severe colchicine-related diarrhea, out of which 12 discontinued it prematurely. There were no major procedural complications in either group. CONCLUSION: In this single-operator retrospective analysis, prophylactic colchicine was not associated with significant reduction in the incidence of postablation chest pain, pericarditis, 30 day hospitalization, ER visits, or AF recurrence or need of cardioversion within first 30 days after HPSD ablation for AF. However, its usage was associated with significant diarrhea. This study concludes no additional advantage of prophylactic use of colchicine after HPSD AF ablation.

Radiation-Associated Pericardial Disease.

PURPOSE OF REVIEW: This review highlights the literature related to pericardial injury following radiation for oncologic diseases. RECENT FINDINGS: Radiation-associated pericardial disease can have devastating consequences. Unfortunately, there is considerably less evidence regarding pericardial syndromes following thoracic radiation as compared to other cardiovascular outcomes. Pericardial complications of radiation may arise acutely or have an insidious onset several decades after treatment. Transthoracic echocardiography is the screening imaging modality of choice, while cardiac magnetic resonance imaging further characterizes the pericardium and guides treatment decision-making. Cardiac CT can be useful for assessing pericardial calcification. Ongoing efforts to lessen inadvertent cardiac injury are directed towards the revision of radiation techniques and protocols. As survival of mediastinal and thoracic malignancies continues to improve, radiation-associated pericardial disease is increasingly relevant. Though advances in radiation oncology demonstrate promise in curtailing cardiotoxicity, the long-term effects pertaining to pericardial complications remain to be seen.

Impact of Periprocedural Colchicine on Postprocedural Management in Patients Undergoing a Left Atrial Appendage Ligation Using LARIAT.

INTRODUCTION: Left atrial appendage (LAA) can be effectively and safely excluded using a novel percutaneous LARIAT ligation system. However, due to pericardial catheter manipulation and LAA ligation and subsequent necrosis, postprocedural course is complicated by pericarditis. We intended to evaluate the preprocedural use of colchicine on the incidence of postprocedural pericardial complications. METHODS AND RESULTS: In this multicenter observational study, we included all consecutive patients who underwent LARIAT procedure at the participating centers. Many patients received periprocedural colchicine at the discretion of the physician. We compared the postprocedural outcomes of patients who received prophylactic periprocedural colchicine (colchicine group) with those who did not receive colchicine (standard group). A total of 344 consecutive patients, 243 in the "colchicine group" and 101 in the "standard group," were included. The mean age, median CHADS2VASc score, and HASBLED scores were 70 ± 11 years, 3 ± 1.7, and 3 ± 1.1, respectively. There were no significant differences in major baseline characteristics between the two groups. Severe pericarditis was significantly lower in the "colchicine group" compared to the "standard group" (10 [4%] vs. 16 [16%] P<0.0001). The colchicine group, compared to the standard group, had lesser pericardial drain output (186 ± 84 mL vs. 351 ± 83, P<0.001), shorter pericardial drain duration (16 ± 4 vs. 23 ± 19 hours, P<0.04), and similar incidence of delayed pericardial effusion (4 [1.6%] to 3 [3%], P = 0.42) when compared to the standard group. CONCLUSION: Use of colchicine periprocedurally was associated with significant reduction in postprocedural pericarditis and associated complications.

Colchicine in addition to conventional therapy for pericarditis recurrence : An update meta-analysis.

BACKGROUND: Randomized controlled trials (RCTs) have investigated the use of colchicine and conventional therapy for reducing the recurrence of pericarditis in patients with acute pericarditis or post-pericardiotomy syndrome. However, the benefits of these treatments are variable. METHODS: Studies were retrieved from PubMed, the Cochrane Library, and the EMBASE database. RESULTS: We identified nine RCTs with 1832 patients and a mean follow-up of 13.1 months. Overall, colchicine therapy significantly decreased the risk of pericarditis recurrence (odds ratio, OR 0.42; 95 % confidence interval, CI 0.33-0.52; P < 0.001; I2 = 17.0 %). Colchicine therapy was associated with significantly lower rates of pericarditis-associated rehospitalization (OR 0.29; 95 % CI 0.16-0.53; P < 0.0001; I2 = 0.0 %) and persistence of symptoms (OR 0.29; 95 % CI, 0.21-0.41; P = 0.000; I2 = 0.0 %) at 72 h. Adverse events were higher in the colchicine group (relative risk, RR 1.48; 95 % CI, 1.06-2.07; P = 0.02; I2 = 0.0 %). Subgroup analysis showed that recurrence of pericarditis was significantly lower in the colchicine therapy group, irrespective of prednisone use and the cause of pericarditis. CONCLUSION: Colchicine significantly decreases the rate of pericarditis recurrence, regardless of prednisone use and the cause of pericarditis. Larger studies are needed to confirm this effect.

BET 1: Safety and efficacy of colchicine as stand-alone therapy for the prevention of recurrent pericarditis.

A short cut review was carried out looking for evidence of the benefits of using colchicine as a single therapy for acute pericarditis. A literature search was performed but no papers were found to provide evidence of the efficacy of colchicine without the concurrent use of Non-steriodal anti-inflammatory drugs (NSAIDs) for this condition.

Evaluation and Treatment of Pericarditis: A Systematic Review.

IMPORTANCE: Pericarditis is the most common form of pericardial disease and a relatively common cause of chest pain. OBJECTIVE: To summarize published evidence on the causes, diagnosis, therapy, prevention, and prognosis of pericarditis. EVIDENCE REVIEW: A literature search of BioMedCentral, Google Scholar, MEDLINE, Scopus, and the Cochrane Database of Systematic Reviews was performed for human studies without language restriction from January 1, 1990, to August 31, 2015. After literature review and selection of meta-analyses, randomized clinical trials, and large observational studies, 30 studies (5 meta-analyses, 10 randomized clinical trials, and 16 cohort studies) with 7569 adult patients were selected for inclusion. FINDINGS: The etiology of pericarditis may be infectious (eg, viral and bacterial) or noninfectious (eg, systemic inflammatory diseases, cancer, and post-cardiac injury syndromes). Tuberculosis is a major cause of pericarditis in developing countries but accounts for less than 5% of cases in developed countries, where idiopathic, presumed viral causes are responsible for 80% to 90% of cases. The diagnosis is based on clinical criteria including chest pain, a pericardial rub, electrocardiographic changes, and pericardial effusion. Certain features at presentation (temperature >38°C [>100.4°F], subacute course, large effusion or tamponade, and failure of nonsteroidal anti-inflammatory drug [NSAID] treatment) indicate a poorer prognosis and identify patients requiring hospital admission. The most common treatment for idiopathic and viral pericarditis in North America and Europe is NSAID therapy. Adjunctive colchicine can ameliorate the initial episode and is associated with approximately 50% lower recurrence rates. Corticosteroids are a second-line therapy for those who do not respond, are intolerant, or have contraindications to NSAIDs and colchicine. Recurrences may occur in 30% of patients without preventive therapy. CONCLUSIONS AND RELEVANCE: Pericarditis is the most common form of pericardial disease worldwide and may recur in as many as one-third of patients who present with idiopathic or viral pericarditis. Appropriate triage and treatment with NSAIDs may reduce readmission rates for pericarditis. Treatment with colchicine can reduce recurrence rates.

[Internal medicine in the hospital setting]. / Médecine interne hospitalière: l'année en revue.

Management of all pathologies, and in particular that of the most frequent ones, should whenever possible be based on robust evidence and arguments. New studies published this year enable rationalizing of screening in certain clinical situations, more adequate treatment of others, and open the way for novel and apparently very effective treatments. Whether it be the screening of carotid stenosis, the treatment of pericarditis, of heart failure, of chronic obstructive lung disease or spontaneous bacterial peritonitis, paradigm changes are conceivable. This selective review of the literature summarizes certain studies published this year.

Cardiac perforation and lead dislodgement after implantation of a MR-conditional pacing lead: a single-center experience.

OBJECTIVE: The purpose of our study was to determine if the rate of lead-related complications was increased with the Medtronic CapSureFix MRI™ SureScan™ 5086 MRI pacing lead (5086; Medtronic Inc., Minneapolis, MN, USA) compared to the previous generation of Medtronic CapSureFix Novus™ 5076 pacing lead (5076). BACKGROUND: The 5086 lead is a newly introduced active-fixation pacemaker lead designed to be used conditionally in a magnetic resonance (MR) scanner. This lead has specific design changes compared to the previous generation of 5076 pacing leads. METHODS: This study was a retrospective case control study of 65 consecutive patients implanted with two 5086 leads compared to 92 consecutive control patients implanted with two 5076 leads over a 14-month period at a high-volume tertiary care hospital. RESULTS: Pericarditis, pericardial effusion, cardiac tamponade, or death within 30 days of implant were seen in eight patients from the 5086 cohort and two from the 5076 cohort (odds ratio 6.3, 95% confidence interval 1.3-30.8, P = 0.02). Lead dislodgement occurred in four of the 5086 patients and in none of the 5076 patients (P < 0.03). CONCLUSIONS: In a high-volume center, the incidence of pericarditis, cardiac perforation, tamponade, death, and lead dislodgement was significantly higher with the MR-conditional Medtronic 5086 lead when compared to the previous generation Medtronic 5076 lead.

Scedosporium prolificans pericarditis and mycotic aortic aneurysm in a lung transplant recipient receiving voriconazole prophylaxis.

Despite the adoption of antifungal prophylaxis, fungal infections remain a significant concern in lung transplant recipients. Indeed, some concern exists that such prophylaxis may increase the risk of infection with drug-resistant fungal organisms. Here, we describe a case of disseminated Scedosporium prolificans infection, presenting as pericarditis, which developed in a lung transplant patient receiving prophylactic voriconazole for 8 months. The epidemiology and clinical presentation of S. prolificans infections are reviewed, and controversies surrounding antifungal prophylaxis and the development of resistant infections are discussed.

Prophylactic Colchicine After Radiofrequency Ablation of Atrial Fibrillation: The PAPERS Study.

BACKGROUND: Pericarditis is common after radiofrequency ablation for atrial fibrillation (AF). OBJECTIVES: Study investigators hypothesized an empirical post-AF ablation treatment protocol with colchicine may reduce the incidence and severity of pericarditis. PAPERS (Post-Ablation PEricarditis Reduction Study) aimed to quantify the risks and benefits associated with prophylactic use of colchicine to prevent pericarditis following AF ablation. METHODS: PAPERS is a multicenter, prospective, randomized controlled study. Patients were randomized on the day of the procedure to receive no postprocedure prophylaxis (group A; standard of care arm) or colchicine 0.6 mg orally twice daily for 7 days starting immediately post-procedure (group B; study arm). All participants underwent a follow-up survey at 14 days postoperatively. The primary endpoint was the development of clinical pericarditis within 2 weeks following ablation. Secondary outcomes included the incidence of pericarditis by ablation type and medical therapy. RESULTS: Among 139 patients enrolled, 66 were randomized to standard of care (group A), and 73 patients were randomized to the colchicine arm (group B). The primary outcome of clinical pericarditis was reached in 7 of 66 (10.6%) patients in group A and in 7 of 73 (9.6%) patients in group B (P = 0.84). The rate of gastrointestinal discomfort was 10 of 66 (15%) in group A and 34 of 73 (47%) in group B (P < 0.001). There was an increased incidence of pericarditis in patients who underwent cavotricuspid isthmus ablation (17 of 50; 34%) in addition to pulmonary vein isolation (6 of 69; 8.7%; P = 0.001). CONCLUSIONS: Prophylactic colchicine therapy initiated after the ablation procedure in patients with AF did not affect the incidence of post-ablation pericarditis and was associated with an increased incidence of gastrointestinal side effects.

Colchicine for recurrent pericarditis (CORP): a randomized trial.

BACKGROUND: Recurrence is the most common complication of pericarditis, affecting 10% to 50% of patients. OBJECTIVE: To evaluate the efficacy and safety of colchicine for the secondary prevention of recurrent pericarditis. DESIGN: Prospective, randomized, double-blind, placebo-controlled multicenter trial. (ClinicalTrials.gov registration number: NCT00128414) SETTING: 4 general hospitals in urban areas of Italy. PATIENTS: 120 patients with a first recurrence of pericarditis. INTERVENTION: In addition to conventional treatment, patients were randomly assigned to receive either placebo or colchicine, 1.0 to 2.0 mg on the first day followed by a maintenance dose of 0.5 to 1.0 mg/d, for 6 months. MEASUREMENTS: The primary study end point was the recurrence rate at 18 months. Secondary end points were symptom persistence at 72 hours, remission rate at 1 week, number of recurrences, time to first recurrence, disease-related hospitalization, cardiac tamponade, and rate of constrictive pericarditis. RESULTS: At 18 months, the recurrence rate was 24% in the colchicine group and 55% in the placebo group (absolute risk reduction, 0.31 [95% CI, 0.13 to 0.46]; relative risk reduction, 0.56 [CI, 0.27 to 0.73]; number needed to treat, 3 [CI, 2 to 7]). Colchicine reduced the persistence of symptoms at 72 hours (absolute risk reduction, 0.30 [CI, 0.13 to 0.45]; relative risk reduction, 0.56 [CI, 0.27 to 0.74]) and mean number of recurrences, increased the remission rate at 1 week, and prolonged the time to subsequent recurrence. The study groups had similar rates of side effects and drug withdrawal. LIMITATION: Multiple recurrences and neoplastic or bacterial causes were excluded. CONCLUSION: Colchicine is safe and effective for secondary prevention of recurrent pericarditis.

Could Amifostine Prevent Experimental Radiotherapy-Induced Acute Pericarditis?

BACKGROUND: Amifostine is a powerful antioxidant that is one of the documented three chemo-radio prototectants recommended for clinical use. There is no data exploring amifostine in prevention of acute pericardial damage. We aimed to investigate whether amifostine has protective effect against acute pericardial injury due to radiotherapy in an experimental rat model. METHODS: Twenty-four rats were divided into four groups: control group, radiotherapy-only group, amifostine-only group, radiotherapy+amifostine group. In groups receiving radiotherapy, hearts were irradiated with a Co 60 teletherapy device at a distance of 80 cm and 20 Gy at a depth of 2 cm. Thirty minutes before interventions, 200 mg/kg amifostine or same volume 0.9% NaCl were administered intraperitoneally. Subjects were sacrificed 24 hours after the procedure. Pericardial histopathological changes were investigated by light microscopy. RESULTS: There was focal inflammation of >= 50% in all rats exposed-to-radiotherapy. All groups receiving radiotherapy revealed a significant increase in pericardial inflammation compared to the groups that did not receive irradiation (p<0.05). There was no difference between the radiotherapy-only group and amifostine+radiotherapy group for pericardial inflammatory response (p>0.05). CONCLUSION: Acute pericarditis was detected in all rats receiving radiotherapy. There was no positive effect of amifostine administration before radiotherapy on acute pericardial inflammation.

Preparation and evaluation of chicken embryo-adapted fowl adenovirus serotype 4 vaccine in broiler chickens.

The current study was planned to develop an efficient vaccine against hydropericardium syndrome virus (HSV). Currently, formalin-inactivated liver organ vaccines failed to protect the Pakistan broiler industry from this destructive disease of economic importance. A field isolate of the pathogenic hydropericardium syndrome virus was adapted to chicken embryos after four blind passages. The chicken embryo-adapted virus was further serially passaged (12 times) to get complete attenuation. Groups of broiler chickens free from maternal antibodies against HSV at the age of 14 days were immunized either with 16th passage attenuated HSV vaccine or commercially formalized liver organ vaccine. The antibody response, measured by enzyme-linked immunosorbent assay was significantly higher (P < 0.05) in the group immunized with the 16th passage attenuated HSV vaccine compared to the group immunized with liver organ vaccine at 7, 14, and 21 days post-immunization. At 24 days of age, the broiler chickens in each group were challenged with 10(3.83) embryo infectious dose(50) of pathogenic HSV and were observed for 7 days post-challenge. Vaccination with the 16th passage attenuated HSV gave 94.73% protection as validated on the basis of clinical signs (5.26%), gross lesions in the liver and heart (5.26%), histopathological lesions in the liver (1.5 ± 0.20), and mortality (5.26%). The birds inoculated with liver organ vaccine showed significantly low (p < 0.05; 55%) protection estimated on the basis of clinical signs (40%), gross lesions in the liver and heart (45%), histopathological lesions in the liver (2.7 ± 0.72), and mortality (35%). Birds in the unvaccinated control group showed high morbidity (84%), mortality (70%), gross (85%), and histopathological lesions (3.79 ± 0.14) with only 10% protection. In conclusion, this newly developed HSV vaccine proved to be immunogenic and has potential for controlling HSV infections in chickens.

[Posttraumatic pericarditis - the treatment and prophylaxis].

Results of treatment of 100 patients with posttraumatic pericarditis after stab (n=79) and blunt (n=21) thoracic trauma. Factors, leading to pericarditis onset, were primary infection, direct heart and pericardium injury (87,3%), inadequate pericardial cavity drainage (13,9%), insufficient medicamental pericarditis prophylaxis postoperatively (8,9%). Late medical recourse after blunt trauma of the thorax had led to pericarditis onset due to clotted hemothorax (23,8%), exudative pleurisy (19%) and pleural empyema (14,3%). Early diagnose and complex conservative treatment of posttraumatic pericarditis allowed recover in 78,5% (n=62) and 81% (n=17) of patients with stab and blunt thoracic trauma, respectively. Pericardial cavity drainage with intrapericardial streptokinase introduction proved to be an effective method of treatment of fibrinopurulent pericarditis.

Colchicine for the primary and secondary prevention of pericarditis: an update.

OBJECTIVE: To review the efficacy and safety of colchicine as primary and secondary prophylaxis for pericarditis. DATA SOURCES: We searched MEDLINE, EMBASE, PubMed, BIOSIS Previews, International Pharmaceutical Abstracts, Web of Science, and CENTRAL for controlled studies from database inception date to July 2009. Search terms included colchicine, pericarditis, and postpericardiotomy syndrome (PPS). STUDY SELECTION AND DATA EXTRACTION: Prospective, randomized, controlled trials investigating the use of colchicine in preventing pericarditis were included. Data extracted included design, inclusion criteria, demographics, interventions, background therapy, and pericarditis-related clinical outcomes. DATA SYNTHESIS: Data were synthesized qualitatively, given variable study designs. Three trials were identified. A single trial examining primary prevention evaluated the use of colchicine versus placebo for preventing PPS in patients undergoing cardiopulmonary bypass grafting. No significant reduction in PPS was found. Two studies examined secondary prevention of pericarditis, comparing colchicine plus aspirin versus aspirin alone. One study examined using these comparators to treat a first episode of pericarditis. After 3 months, there was a significant reduction in recurrent pericarditis with colchicine plus aspirin (11.7% vs 33%; p = 0.009). Another study examined this same regimen in recurrent pericarditis, finding a significant reduction in recurrence after 6 months (21% vs 45%; p = 0.02). CONCLUSIONS: Despite limitations in study designs, current evidence suggests a role for colchicine in the secondary prophylaxis for recurrent pericarditis. The evidence for use of colchicine as primary prophylaxis in PPS is indeterminate; therefore, colchicine cannot be recommended routinely. While colchicine should be recommended for the prevention of recurrent pericarditis, questions regarding the optimal regimen and long-term safety profile need to be further elucidated.

Nocardia farcinica pericarditis after kidney transplantation despite prophylaxis.

A deceased-donor kidney transplant recipient developed purulent pericarditis caused by Nocardia despite trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis for Pneumocystis jirovecii. She was treated empirically with ceftriaxone and amikacin and subsequently underwent sternotomy with drainage of an intrapericardial abscess. Culture and susceptibility data demonstrated Nocardia farcinica, which was susceptible to SMX and amikacin, although resistant to ceftriaxone. Nocardia asteroides, the more common human pathogen, is generally susceptible to third-generation cephalosporins and TMP-SMX. N. farcinica is rare in the United States, more virulent and resistant than N. asteroides, and is more likely to cause disseminated disease. Successful therapy of disseminated Nocardia infections is dependent upon choice of appropriate empiric antibiotics in addition to surgical drainage of purulent fluid collections. TMP-SMX prophylaxis may not be sufficient to prevent infections due to Nocardia species in all immunosuppressed transplant recipients. Here, a rare complication of this unusual pathogen is discussed.

Acupuncture-Related Cardiac Complications: A Systematic Review.

BACKGROUND: The objective of this study is to review acupuncture-related cardiac complications, such as infective endocarditis (IE), cardiac tamponade (CT), pericarditis, and cardiac rupture, as there is no known reported literature to determine the burden of cardiac adverse events due to acupuncture. METHODS: Structured computerized databases were searched using the special Medical Subject Heading (MeSH). Manual search using the references of relevant articles was also performed. RESULTS: A total of 133 articles were initially retrieved, but careful reading resulted in only 30 cases of relevant cardiac adverse events. There were 8 articles of infective complications (mostly IE), while 22 articles of CT have been reported to date. The diagnoses were made with echocardiography and patients were treated with intravenous antibiotics. The source of the infection was mostly localized to acupuncture needle prick sites, such as earlobes and legs. Mortality rate for post-acupuncture CT was not significantly higher than infective cardiac complication (Pearson's Chi-square = 0.559; likelihood ratio = 0.553). However, the weighted percentage of death was about 80% in CT vs only 20% mortality for infective cardiac complications. On the other hand, CT was the most common presentation when the needle pricks were close to the heart, and had a clinical presentation of hypotension and venous distention. CONCLUSIONS: Although the universally reported complications of acupuncture are low, and the procedure itself has been deemed low risk in acupuncture-related literature, these cardiac complications are alarming. To avoid these potentially catastrophic consequences, more education needs to be done for adopting safer techniques.

Duration of immunity for an inactivated Mycoplasma hyorhinis vaccine in pigs.

Mycoplasma hyorhinis (Mhr) is a pathogen of pigs causing polyserositis and polyarthritis. The most susceptible population are nursery pigs of approximately 7 weeks of age, although we have shown that clinical signs can persist into finishing aged animals after a late-nursery infection. We have previously demonstrated the efficacy of a novel inactivated Mhr vaccine for the reduction of lameness and polyserositis in caesarian-derived colostrum-deprived (CDCD) pigs vaccinated at 3 weeks and challenged with Mhr at 6 weeks of age. Here we evaluated the duration of immunity (DOI) of the same vaccine. Vaccine or placebo was administered to CDCD pigs at 3 weeks of age. Pigs were challenged with Mhr at either 10 weeks of age (=7 week DOI) or 13 weeks of age (=10 week DOI). In the 7 week DOI, vaccination provided significant reductions in lameness (p = 0.0018), arthritis (p = 0.0002), and pericarditis (p = 0.0312) versus the placebo control. In the 10 week DOI, a significant reduction in arthritis (p = 0.0320) was observed in the vaccine group as compared to the placebo group. Both vaccine groups showed a significant increase (p < 0.0001) in the post-challenge average daily gain (ADG), gaining 0.2 kg/day more than their respective placebo groups.

Chemotherapy and cardiotoxicity.

Newer cancer therapies have improved the survival of patients with cancer and, in some cases, turned cancer into a chronic disease. Patients are now surviving long enough for the adverse cardiovascular effects of some cancer therapies to become apparent. The anthracyclines are perhaps the most notorious offenders. Acute reactions include chest discomfort and shortness of breath consistent with a myopericarditis. Toxicity can also develop months after the last chemotherapy dose and typically presents as new onset heart failure with left ventricular systolic dysfunction. Late reactions are seen years after presentation as new-onset cardiomyopathy, often in patients who were treated for childhood neoplasms. 5-Fluorouracil, its prodrug capecitabine, and trastuzumab, a tumor-specific antibody, have also been associated with cardiotoxicity. Until adequate predictive models, prevention modalities, and treatments can be identified, the clinician's focus should be on aggressive monitoring for early signs of cardiac dysfunction in order to prevent severe systolic dysfunction and its concomitant morbidity and mortality.