Amr Idris

Right ventricular dysplasia: management and treatment in light of current evidence

ABSTRACT Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare cardiovascular disease that predisposes to ventricular arrhythmias potentially leading to sudden cardiac death (SCD). ARVC varies considerably with multiple clinical presentations, ranging from no symptoms to cardiac arrhythmias to SCD. ARVC prevalence is not well known, but the estimated prevalence in the general population is 1:5000. Diagnosis of ARVC can be made by using the Revised European Society of Cardiology criteria for ARVC that includes ventricular structural and functional changes, ECG abnormalities, arrhythmias, family and genetic factors. The management of ARVC is focused on prevention of lethal events such as SCD. Implantable cardioverter defibrillator placement is the only proven mortality benefit in treatment of ARVC. Other treatment strategies include medications such as beta blockers and antiarrhythmics, radiofrequency ablation, surgery, cardiac transplantation, and lifestyle changes. All these interventions help in symptomatic treatment but none of them have proved to decrease mortality rates. ARVC is a progressive disease that leads to SCD if not treated appropriately. Management of these diseases has been a challenge for physicians. With the advent of technology and many new drugs/devices under clinical investigation, this might change in the future. However, while advances in technologies have helped elucidate many aspects of these diseases, many mysteries still remain of this unique disease. With continued research, we can expect more cost-effective and patient-friendly drug therapies and ablation techniques to be developed in the near future.

Loperamide abuse cardiotoxicity. Should loperamide still be an over the counter medication

ABSTRACT Loperamide is an over‐the‐counter anti‐diarrheal medication that is inexpensive, easily accessible, and widely used. It is generally thought to be safe and effective without the potential for abuse. However, recent discovery of its ability to treat opioid withdrawal symptoms at high doses has led to not only its abuse, but also the need to recognize its cardiotoxicity due to the ability to prolong the QTc interval. We report a case of a 33 year old female with a history of opioid dependence who presented to the emergency department with acute onset shortness of breath and generalized weakness who was subsequently found to be in ventricular tachycardia. Electrocardiogram showed prolongation of the QTc and the patient later admitted to ingestion of 70 loperamide pills daily for the past year in order to alleviate her opioid withdrawal symptoms. Due to increased loperamide abuse and toxicity displayed within the last several years, public and health provider awareness should be optimized to fully understand its lethality, and stricter regulations on its availability to the general population should be considered. Even in asymptomatic patients with ECG abnormalities, emergency medicine physicians should admit them for further monitoring and aggressive medical therapy.

Ultrasound-guided versus palpation-guided radial artery catheterization in adult population: A systematic review and meta-analysis of randomized controlled trials

Background The radial artery (RA) is routinely used for both hemodynamic monitoring and for cardiac catheterization. Although cannulation of the RA is usually undertaken through manual palpation, ultrasound (US)‐guided access has been advocated as a mean to increase cannulation success rates and to lower RA complications; however, the published data are mixed. We sought to evaluate the impact of US‐guided RA access compared with palpation alone on first‐pass success to access RA. Methods and Results Meta‐analysis of 12 randomized controlled trials comparing US‐guided with palpation‐guided radial access in 2,432 adult participants was done. Hemodynamic monitoring was the most common reason for RA catheterization. Only 2 randomized controlled trials evaluated patients undergoing cardiac catheterization. Ultrasound‐guided radial access was associated with increased first‐attempt success rate (risk ratio [RR] 1.35, 95% CI 1.16‐1.57]) and decreased failure rate (RR 0.52, 95% CI 0.32‐0.87). There were no significant differences in the risk of hematoma (RR 0.43, 95% CI 0.27‐1.06), the mean time to first successful attempt (mean difference 25.13 seconds, 95% CI −1.06 to 51.34) or to any successful attempt (mean difference −4.74 seconds; 95% CI −22.67 to 13.18) between both groups. Conclusions Ultrasound‐guided technique for RA access has higher first‐attempt success and lower failure rate compared with palpation alone, with no significant differences in access site hematoma or time to a successful attempt. These findings support the routine use of US guidance for RA access.