Eman M. El-Sharkawy

The haemodynamic dilemma in emergency care: Is fluid responsiveness the answer? A systematic review

BackgroundFluid therapy is a common and crucial treatment in the emergency department (ED). While fluid responsiveness seems to be a promising method to titrate fluid therapy, the evidence for its value in ED is unclear. We aim to synthesise the existing literature investigating fluid responsiveness in ED.MethodsMEDLINE, Embase and the Cochrane library were searched for relevant peer-reviewed studies published from 1946 to present.ResultsA total of 249 publications were retrieved of which 22 studies underwent full-text review and eight relevant studies were identified. Only 3 studies addressed clinical outcomes - including 2 randomised controlled trials and one feasibility study. Five articles evaluated the diagnostic accuracy of fluid responsiveness techniques in ED. Due to marked heterogeneity, it was not possible to combine results in a meta-analysis.ConclusionHigh quality, adequately powered outcome studies are still lacking, so the place of fluid responsiveness in ED remains undefined. Future studies should have standardisation of patient groups, the target response and the underpinning theoretic concept of fluid responsiveness. The value of a fluid responsiveness based fluid resuscitation protocol needs to be established in a clinical trial.

The Role of 64/128-Slice Multidetector Computed Tomography to Assess the Progression of Coronary Atherosclerosis

Objectives We studied the progression of coronary atherosclerosis over time as detected by multidetector computed tomography (MDCT) in relation to risk factors and plaque composition. Background Studies using MDCT are limited to the assessment of the degree of stenosis without taking into consideration the plaque composition that is seen by MDCT. Methods This study included 200 patients, complaining of chest pain and referred to do 64/128-contrast–enhanced MDCT for the second time, and both studies were retrieved and evaluated for the presence of plaque, plaque type, vessel wall remodeling, percent area, and diameter stenosis and compared in both studies. Plaque progression over time and its association with risk factors were determined. Results We included 200 patients, and 348 plaques were detected by 64/128 MDCT. The duration between follow-up and baseline studies was 25.9 ± 19.2 month. In all, 200 plaques showed progression (57.47%), 122 were stable (35.06%), and 26 regressed (7.47%). In longitudinal regression analysis, the presence of history of diabetes mellitus and dyslipidemia and the absence of intraplaque calcium deposits were independently associated with plaque progression over time (P < 0.0001). Conclusion Coronary plaque burden of patients with chest pain and no history of acute coronary syndrome significantly increased over time. Progression is dependent on plaque composition and cardiovascular risk factors. Larger studies and longer follow-up period are needed to confirm the determinant factors for plaque progression.

Study of serum apelin and its relation to obesity-associated hypertension

Introduction Over the past few decades obesity has become a major burden on health worldwide. The prevalence of hypertension has increased with a significant increase in the prevalence of overweight and obesity. Recent studies indicate an important role of adipose tissue hormones called adipokines in obesity-associated complications. Apelin has recently been added to the family of adipokines. One of the physiologic functions of the apelin/APJ system is regulation of the cardiovascular function. The aim of this study was to determine the relation of serum apelin to obesity-associated hypertension as well as to myocardial performance. Patients and methods The study included 30 obese hypertensive patients, 30 obese nonhypertensive patients, and 25 age-matched and sex-matched controls. In all studied participants we determined the lipid profile, serum insulin, fasting blood glucose level, HOMA-IR, serum apelin, and echocardiographic results of left ventricular systolic and diastolic function. Results Higher levels of fasting blood glucose, fasting serum insulin, HOMA-IR, triglycerides, total cholesterol, and low-density lipoprotein were detected in obese hypertensive and nonhypertensive patients. Left ventricular mass index (LVMI) was increased in both obese hypertensive and nonhypertensive patients in comparison with healthy individuals. Left ventricular ejection fraction and E/A ratio were significantly lower in hypertensive obese versus nonhypertensive obese individuals (P = 0.004 and <0.001, respectively), whereas LVMI was higher in hypertensive versus nonhypertensive patients (P < 0.001). Apelin levels were significantly equally higher in obese hypertensive and nonhypertensive patients (6.10 ± 1.88 and 6.40 ± 1.60 ng/ml) compared with controls (4.22 ± 0.86 ng/ml, P < 0.001). In hypertensive obese individuals, serum apelin correlated negatively with left ventricular ejection fraction (P = 0.02) and directly with E/A ratio (P = 0.03). Conclusion Apelin levels are significantly higher in obese hypertensive and nonhypertensive patients. This increase might be a compensatory mechanism against myocardial dysfunction with obesity.

A right coronary artery aneurysm presenting as a mass in echocardiography

A 67-year-old male patient with hypertension presented for preoperative assessment. He complained of mild exertional dyspnea. Electrocardiogram and laboratory investigations were within normal limits. Echocardiogram revealed normal dimensions, preserved systolic function and evidence of diastolic dysfunction (E/A 0.6, E/e′ 7.2). However, a cystic echo-lucent mass measuring 23 × 24 mm was evident at the atrioventricular groove in close proximity to the right atrium in sub costal and modified apical four-chamber views (Fig. 1a, b). Pulsed wave Doppler on the mass reveled pulsatile flow (Fig 1c). Subsequently, cardiac computed tomography showed ectatic right coronary artery (RCA) with multiple partially thrombosed aneurysms with calcified walls, the largest was in the distal RCA which measures 39 mm in maximum dimension (Fig. 1d). Scan downward in the descending aorta revealed large infra-renal partially thrombosed abdominal aortic aneurysm measuring 54 mm. Myocardial perfusion imaging was negative. Patient was started on aspirin, statins and furosemide. In addition, biannual ultrasound was recommended to follow-up on the abdominal aortic aneurysm. Coronary artery aneurysm (CAA) is a localized dilatation of a coronary artery segment more than 1.5-fold the normal size of adjacent normal segments [1, 2]. CAAs are mainly caused by Kawasaki disease, coronary atherosclerosis or autoimmune diseases. Regarding our patient, he lacked any manifestations that would link him to a systemic or an autoimmune disorder and he had a negative inflammatory and autoimmune panel. Hence, we concluded that the cause was atherosclerosis. In addition, atherosclerosis is the most common cause in his age group and it is associated with hypertension and infrarenal aneurysms. Patients may be asymptomatic or can present with dyspnea, chest pain or palpitations. Rarely it can present clinically as a murmur. In our case, he presented with dyspnea which was attributed to the diastolic dysfunction. Several modalities can diagnose CAAs, such as coronary angiography, intra vascular ultra sound (IVUS), computed tomography, magnetic resonance imaging and echocardiography. Nowadays, IVUS is considered the gold standard, however, computed tomography is a very promising noninvasive modality [3]. There is no standard approach for all cases when it comes to treatment. Hence, therapy should be directed towards the cause and is tailored on every patient. Options include percutaneous coronary intervention, coronary artery bypass and medical treatment [4].

Analysis of Bleeding Complications in Acute Coronary Syndrome: Comparison of Effect of Tirofiban in Diabetic and Non-Diabetic Patients

Background: Coronary artery disease (CAD) is the most prevalent manifestation of cardiovascular diseases and is associated with high mortality and morbidity. The clinical presentations of CAD include silent ischemia, stable angina pectoris, unstable angina, myocardial infarction (MI), heart failure, and sudden death. Objective: This study was designed to define the frequency of hemorrhagic complications and to identify clinical variables associated with increased risk of bleeding complications in diabetic versus non-diabetic patients presented with acute coronary syndrome whom received aspirin, clopidogrel and heparin only or in combination with GPIIb/IIIa receptors blockade (Tirofiban) and to detect any bleeding complications in all patients during the period of admission in the hospital. Patients and Methods: 150 patients with ACS were divided into two groups, 82 diabetic patients and 68 nondiabetic patients. 40 patients out of total sample received tirofiban. Assessment of in hospital TIMI bleeding, GRACE and CRUSADE risk scores was estimated for all of them. Results: We observed that, there is no statistically significant difference in TIMI bleeding in both heparin and tirofiban group in diabetic versus non-diabetic patients. Cardiac catheterization access site was the most frequent location of bleeding most likely secondary to the high rate of coronary angiography performed in the study. Tirofiban added to heparin did not increase the risk of bleeding at the vascular access site.Conclusion: There was no statistically significant increase in all TIMI bleeding, thrombocytopenia or blood transfusions with the combination of tirofiban with heparin in both diabetic and non-diabetic patients.

What is the normal haemodynamic response to passive leg raise? A study of healthy volunteers

Objective Passive leg raise (PLR) is used as self-fluid challenge to optimise fluid therapy by predicting preload responsiveness. However, there remains uncertainty around the normal haemodynamic response to PLR with resulting difficulties in application and interpretation in emergency care. We aim to define the haemodynamic responses to PLR in spontaneously breathing volunteers using a non-invasive cardiac output monitor, thoracic electrical bioimpedance, TEB (PLR-TEB). Methods We recruited healthy volunteers aged 18 or above. Subjects were monitored using TEB in a semirecumbent position, followed by PLR for 3 min. The procedure was repeated after 6 min at the starting position. Correlation between the two PLRs was assessed using Spearman’s r (rs). Agreement between the two PLRs was evaluated using Cohen Kappa with responsiveness defined as ≥10% increase in stroke volume. Parametric and non-parametric tests were used as appropriate to evaluate statistical significance of baseline variables between responders and non-responders. Results We enrolled 50 volunteers, all haemodynamically stable at baseline, of whom 49 completed the study procedure. About half of our subjects were preload responsive. The ∆SV in the two PLRs was correlated (rs=0.68, 95% CI 0.49 to 0.8) with 85% positive concordance. Good agreement was observed with Cohen Kappa of 0.67 (95% CI 0.45 to 0.88). Responders were older and had significantly lower baseline stroke volume and cardiac output. Conclusion Our results suggest that the PLR-TEB is a feasible method in spontaneously breathing volunteers with reasonable reproducibility. The age and baseline stroke volume effect suggests a more complex underlying physiology than commonly appreciated. The fact that half of the volunteers had a positive preload response, against the 10% threshold, leads to questions about how this measurement should be used in emergency care and will help shape future patient studies.

Carney Complex: A Rare Case of Multicentric Cardiac Myxoma Associated with Endocrinopathy

Carney complex is a rare autosomal dominant disorder characterized by multiple tumors, including cardiac and extracardiac myxomas, skin lesions, and various endocrine disorders. We are reporting a 21-year-old female patient with past surgical history significant for excision of a cutaneous myxoma who presented with multicentric cardiac myxomas involving the four cardiac chambers. She also presented with endocrinal disorders in the form of an enlarged right lobe of the thyroid, hyperthyroid state, and an incidentally noted adrenal cyst; hence, she was diagnosed with carney complex syndrome.

Long-term prognostic implication of coronary plaque characterization as detected by 64-multidetector computed tomography in Egyptian population

Objectives We aimed to determine the role of multi-detector computed tomography (MDCT) in prognosis of patients with known or suspected coronary artery disease (CAD) by applying plaque characterization and whether obstructive versus non-obstructive plaque volume is a predictor of future cardiac events. Background Vulnerable plaques may occur across the full spectrum of severity of stenosis, underlining that also non-obstructive lesions may contribute to coronary events. Methods We included 1000 consecutive patients with intermediate pretest likelihood of CAD who were evaluated by 64-MDCT. Coronary artery calcium scoring, assessment of degree of coronary stenosis and quantitative assessment of plaque composition and volume were performed. The end point was cardiac death, acute coronary syndrome, or symptom-driven revascularization. Results After a median follow-up of 16 months, 190 patients had suffered cardiac events. In a multivariate regression analysis for events, the total amount of non-calcified plaque (NCP) in non-obstructive lesions was independently associated with an increased hazard ratio for non-fatal MI (1.01–1.9/100-mm3 plaque volume increase, p = 0.039), total amount of obstructive plaque was independently associated with symptoms driven revascularization (p = 0.04) and coronary artery calcium scoring (CACS) was independently associated with cardiac deaths (p = 0.001). Conclusion MDCT is a non-invasive imaging modality with a prognostic utility in patients with known or suspected coronary artery disease by applying plaque characterization and it could identify vulnerable plaques by measuring the total amount of NCP in non-obstructive lesions which could be useful for detecting patients at risk of acute coronary syndrome (ACS) and guide further preventive therapeutic strategies. CACS was shown to be an independent predictor of mortality, while total amount of obstructive volume was shown to be an independent predictor of symptoms driven revascularization.

Parathormone (PTH) is strongly related to left ventricular mass index (LVMI) in hypertensives, obese, and normal control

https://doi.org/10.1016/j.ajme.2017.10.002 2090-5068/ 2017 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer review under responsibility of Alexandria University Faculty of Medicine. ⇑ Corresponding author. E-mail address: Tamer_elsherbiny@alexmed.edu.eg (T.M. Elsherbiny). Samir Naim Assaad , Aliaa Ali El-Aghoury , Eman M. El-Sharkawy , Tamer Mohamed Elsherbiny a,⇑, Ahmed Abdelhameed Osman a