Christoph Pechlaner

Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest

BACKGROUND Thrombolytic therapy during cardiopulmonary resuscitation (CPR) is a controversial issue in emergency medicine practice. This study was conducted to determine whether administration of recombinant tissue plasminogen activator (rt-PA) in out-of-hospital cardiac arrest of non-traumatic aetiology improves CPR outcome. METHODS AND RESULTS A retrospective chart review of 401 patients with out-of-hospital cardiac arrest who were resuscitated by the emergency medical services (EMS) during a 6 year period was performed. A total of 108 patients received rt-PA during CPR and were compared to 216 controls, closely matched according to baseline characteristics, arrival status and ECG findings. Administration of rt-PA was optional. Return of spontaneous circulation (ROSC) occurred in 76 patients under rt-PA treatment (70.4 vs. 51.0% in controls; P=0.001). Fifty-two patients from the lysis group survived the first 24 h (48.1 vs. 32.9% in controls; P=0.003), while 27 (25.9%) survived to discharge. Autopsy reports revealed major bleeding complications in six patients receiving rt-PA treatment. Fulminant intracranial haemorrhage was observed in one patient who received rt-PA and in two cases from the control group. CONCLUSIONS Thrombolytic therapy may improve frequency of return of spontaneous circulation substantially and increase primary survival in patients with non-traumatic cardiac arrest. Serious bleeding complications are not frequently observed under rt-PA treatment.

Incidence and risk of potential adverse drug interactions in the emergency room

OBJECTIVE To determine the incidence and risk factors of potential adverse drug interactions occurring in patients in the emergency department. DESIGN Survey of a random sample of medical records of elderly persons and other adults seeking care at an emergency department. The interactions were determined by a computer programme, reviewed using explicit criteria, and excluded if of uncertain or trivial clinical significance. SETTING University Hospital Medical Emergency Department. PATIENTS A total of 423 randomly selected adults seeking care at a university hospital emergency department. Attendances made by 195 persons over age 60 and 228 younger adults were evaluated. All subjects were treated on an outpatient basis. MAIN OUTCOME MEASURES Seventy percent of attendances led to the prescription of an added medication. In 5.4% of the attendances in which at least one medication was added, the new medication introduced a potential adverse interaction. The number of medications used at attendance was the best predictor of whether a potential interaction would occur. Additional medications prescribed in the emergency department that accounted for most of the added interactions were theophylline, macrolid antibiotics, digitalis glycosides, nonsteroidal anti-inflammatory agents, angiotensin converting-enzyme inhibitors and calcium antagonists. CONCLUSIONS Potential adverse drug interactions were more common in elderly patients because of the higher number of concurrent medications rather than age-based factors. Safeguards need to be introduced to prevent patients from receiving medications in the emergency departments that have the potential to cause adverse interactions.

Plasma Levels of Troponin T After Electrical Cardioversion of Atrial Fibrillation and Flutter

To establish possible myocardial damage by direct-current countershock, we measured plasma levels of troponin T after electrical cardioversion in 33 nonselected patients with atrial fibrillation or flutter. Unchanged normal levels of troponin T indicate that significant myocardial cell injury by shocks in the usual dosage is unlikely to occur.

Plasma levels of procalcitonin and interleukin-6 in acute myocardial infarction.

Estimation of cardiac morbidity in patients after major surgery is a difficult problem. In addition, infectious complications seriously decrease potential beneficial outcome after cardiovascular surgery. The present study assessed the use of a newer marker of the inflammatory response, procalcitonin, in the field of myocardial infarction, in conjunction with measurements of interleukin-6. Forty-four consecutive cases with acute myocardial infarction were included in the study 4 ± 1.3 h after the onset of symptoms. Plasma levels of procalcitonin and interleukin-6 were obtained at admission, and after 3, 6, 12, 18, 24 and 48 h, using commercially available test kits. The range of levels of interleukin-6 and procalcitonin was about normal at admission. Interleukin-6 levels increased significantly following myocardial infarction, whereas procalcitonin were essentially unchanged, i.e. remained close to the normal level threshold of 0.5 ng/ml; only minor variability occurred with a mean peak level of procalcitonin of 1 ± 0.4 ng/ml. Data demonstrate that, in contrast to the acute phase reactant interleukin-6, plasma levels procalcitonin are not significantly elevated during uncomplicated acute myocardial infarction. This observation may support the role of procalcitonin measurements in the differential diagnosis of infectious and cardiovascular complications after major surgery.

Influence of oral contraceptives on coagulation tests in native blood and plasma

Routine coagulation laboratory tests, clotting times in native (not anticoagulated) whole blood, platelet-rich and platelet-poor plasma, and recalcification times in citrated whole blood, platelet-rich and platelet-poor plasma were performed in 14 healthy premenopausal women. Blood was taken before and after one or two cycles of low-dose oral contraceptives. After oral contraceptives a reduction in clotting time in native platelet-rich plasma and activated partial thromboplastin time were observed. Recalcification times in whole blood and platelet-rich plasma were shorter than clotting times in their native counterparts. The observed changes are compatible with a procoagulant effect seen soon after the start of oral contraceptive use. The absence of these changes in the recalcification times in citrate systems suggests a masking effect of citrate. The reduction in clotting times in native platelet-rich but not in platelet-poor plasma indicates that the hypercoagulability in oral contraceptives users is mainly related to platelets.

The inhibition of oxygen radical release from human neutrophils by resting platelets is reversed by administration of acetylsalicylic acid or clopidogrel

Resting platelets inhibit oxygen radical release from neutrophils. Antiplatelet therapy may support this function by preventing platelet activation. Whether antiplatelet agents affect the antioxidative action of resting platelets in the absence of platelet activation is unknown. The effect of acetylsalicylic acid or clopidogrel administration on the antioxidative action of resting platelets was therefore studied in ten healthy volunteers. Preparations of resting platelets were obtained from 5 subjects each — before, during and after an eight-day course of daily treatment with 100 mg of acetylsalicylic acid or 75 mg of the thienopyridine clopidogrel. Human peripheral blood neutrophils were pretreated with the platelets at a ratio of 1/50 for 45 min; then formyl-Met-Leu-Phe-triggered oxygen radical release was measured fluorometrically. The inhibitory effect of platelets on oxygen radical release from neutrophils which was seen before treatment was abolished by antiplatelet therapy with either of the drugs, and inhibition was restored gradually after discontinuing acetlsalicylic acid/ clopidogrel intake. Results suggest that the protective role of resting platelets in controlling oxygen radical release from neutrophils in the absence of platelet activation may be impaired by antiplatelet therapy.

Influence of continuous veno-venous hemofiltration on argatroban clearance in a patient with septic shock

Sir: Argatroban, a direct thrombin inhibitor approved for heparin-induced thrombocytopenia (HIT), is primarily metabolized by the liver. Thus, dose adjustments are not recommended in renal failure [1, 2]. We report a patient with HIT and multiple organ dysfunction in whom anticoagulation by argatroban appeared to be substantially influenced by continuous veno-venous hemofiltration (CVVH). A 54-year-old woman with a history of rheumatoid arthritis and steroid therapy as well as peripheral arterial disease was admitted to

Decreased Levels of β-Endorphin in Circulating Mononuclear Leukocytes from Patients with Acute Myocardial Infarction

Lymphocytes can be activated to produce and release opioid peptides. We investigated the levels of immunoreactive β-endorphin in peripheral blood mononuclear cells from 11 patients with acute myocardial infarction. The concentrations of β-endorphin in mononuclear leukocytes of 30.2 ± 6.9 pg/106 cells on admission were in the normal range of 20–40 pg/106 cells and decreased significantly to 6.9 ± 1.9 pg/106 cells after 48 h (p < 0.05). Decreased levels of mononuclear leukocyte-associated β-endorphin in acute myocardial infarction may be due to the release of endogenous opioid after stimulation by stress and acute-phase reactants and play a role in inflammation and pain.

Patients with high-risk acute myocardial infarction randomized to one of two treatment strategies: delay and eligibility questions

Grines et al. [(1)][1]reported randomization of patients with high-risk acute myocardial infarction (AMI) to one of two treatment strategies, namely transfer for primary percutaneous transluminal coronary angioplasty (PTCA) or on-site thrombolysis. Randomization required a mean of 44 min (median 32

Enoxaparin for acute coronary syndromes

Goodman et al. [(1)][1]conclude that enoxaparin is a more effective antithrombotic treatment than unfractionated heparin (UFH) for the prevention of rebound ischemia in patients with unstable angina or non-Q-wave myocardial infarction. We suggest an alternative conclusion. Enoxaparin’s plasma