Sachil Shah

Acute Myocardial Infarction During Regadenoson Myocardial Perfusion Imaging

Pharmacologic stress testing uses vasodilators to provide objective evidence of myocardial ischemia. Adenosine and dipyridamole are nonselective adenosine receptor agonists that have been associated with myocardial infarction (MI) during intravenous infusion. Mechanisms postulated for this effect include coronary steal, transmural steal, global hypotension, and direct vasoconstriction. Regadenoson, a direct A2A agonist, was approved for use in stress testing in 2008. We describe a 68‐year‐old man who presented to our institution with typical angina, relieved by nitroglycerin. He did not have electrocardiogram (ECG) changes suggestive of myocardial pathology, and laboratory testing did not reveal a significant rise in troponin‐I levels. To further assess the etiology of his symptoms, he underwent a pharmacologic stress test with regadenoson followed by technetium 99 m sestamibi. Six minutes after regadenoson infusion, the patient developed severe retrosternal chest pain accompanied by ST elevations on ECG. Sublingual nitroglycerin was administered that resolved both the pain and ECG changes. The patient subsequently underwent urgent coronary angiography and was found to have a 95% critical stenosis involving the left anterior descending artery. We conclude this case represents a MI secondary to coronary steal phenomenon induced by regadenoson infusion. Clinicians should be aware this adverse effect can occur despite the improved side‐effect profile of regadenoson. Continuous monitoring of vital signs and the ECG with regular assessment of symptoms is imperative to identify this rare but potentially devastating adverse event.

Non-critical care telemetry and in-hospital cardiac arrest outcomes

BACKGROUND Telemetry is increasingly used to monitor hospitalized patients with lower intensities of care, but its effect on in-hospital cardiac arrest (IHCA) outcomes in non-critical care patients is unknown. HYPOTHESIS Telemetry utilization in non-critical care patients does not affect IHCA outcomes. METHODS A retrospective cohort analysis of all patients in non-critical care beds that experienced a cardiac arrest in a university-affiliated teaching hospital during calendar years 2011 and 2012 was performed. Data were collected as part of AHA Get With the Guidelines protocol. The independent variable and exposure studied were whether patients were on telemetry or not. Telemetry was monitored from a central location. The primary endpoint was return of spontaneous circulation (ROSC) and the secondary end point was survival to discharge. RESULTS Of 123 IHCA patients, the mean age was 75±15 and 74 (61%) were male. 80 (65%) patients were on telemetry. Baseline demographics were similar except for age; patients on telemetry were younger with mean age of 70.3 vs. 76.8 in the non-telemetry group (p=0.024). 72 patients (60%) achieved ROSC and 46 (37%) achieved survival to discharge. By univariate analysis, there was no difference between patients that had been on telemetry vs. no telemetry in ROSC (OR=1.13, p=0.76) or survival to discharge (OR=1.18, p=0.67). Similar findings were obtained with multivariate analysis for ROSC (0.91, p=0.85) and survival to discharge (OR=0.92, p=0.87). CONCLUSIONS The use of cardiac telemetry in non-critical care beds, when monitored remotely in a central location, is not associated with improved IHCA outcomes.

Plasma Renin Activity Testing to Guide Triple Antirenin System Drug Therapy in a Patient With Difficult-to-Treat Hypertension

Objective: To report a case of difficult-to-treat hypertension ultimately managed with triple antirenin (anti-R) therapy using plasma renin activity (PRA) to guide medication selection. Case Summary: A 66-year-old white man was referred to the cardiology pharmacotherapy clinic for difficult-to-treat hypertension. His initial office blood pressure (BP) was 152/71 mm Hg on diltiazem and chlorthalidone. After a series of medication adjustments based on serial PRA measurements, the patient achieved his target BP with a regimen that included 3 anti-R angiotensin system medications: carvedilol, valsartan, and aliskiren. Discussion: Despite continued progress in the understanding and advances in pharmacological therapy for hypertension, uncontrolled hypertension remains a major problem. The most common strategy to control hypertension is the stepped-care approach with progressive addition of medications to eventually reach BP goal. An alternative approach includes the use of PRA measurements to guide both the addition and removal of drugs in an attempt to effectively control BP. At times, this has the potential to result in a drug regimen that is incongruous with current guidelines and practice recommendations. However, if this results in more effective BP control with the same, or fewer, number of medications, it may represent a reasonable alternative. Conclusion: This case report illustrates a real-world application of PRA-guided therapeutics in a patient with difficult-to-treat hypertension. It highlights how a personalized approach can lead to BP control with a more streamlined regimen than would likely result if a stepped-care approach was used.

Primary Prevention of Cardiovascular Disease

Cardiovascular disease (CVD) is a spectrum of disorders that includes stroke, coronary heart disease (CHD) and peripheral vascular disease (PVD). CVD is the UKs biggest cause of death, with over 191 000 deaths a year. The extent to which CVD affects the health of the population and the financial burden this places on the National Health Service (NHS) makes it an important modifiable disease. Preventing CVD is now a significant role of the general practice team.

Ultrafiltration versus intravenous loop diuretics in patients with acute decompensated heart failure: a meta-analysis of clinical trials

Background Intravenous loop diuretics are the first-line therapy for acute decompensated heart failure (ADHF) but many patients are discharged with unresolved congestion resulting in higher re-hospitalization and mortality rates. Ultrafiltration (UF) is a promising intervention for ADHF. However, studies comparing UF to diuretics have been inconsistent in their clinical outcomes. Methods A comprehensive literature search was performed. Trials were included if they met the following criteria: (1) randomization with a control group, (2) comparison of UF with a loop diuretic, and (3) a diagnosis of ADHF. Results When compared to diuretics, UF was associated with a reduced risk of clinical worsening (odds ratio (OR) 0.57, 95% CI: 0.38-0.86, P-value 0.007), increased likelihood for clinical decongestion (OR 2.32, 95% CI: 1.09-4.91, P-value 0.03) with greater weight (0.97 Kg, 95% CI: 0.52-1.42, P-value <0.0001) and volume reduction (1.11 L, 95% CI: 0.68-1.54, P-value <0.0001). The overall risk of re-hospitalization (OR 0.92, 95% CI: 0.62-1.38, P-value 0.70), return to emergency department (OR 0.69, 95% CI: 0.44-1.08, P-value 0.10) and mortality (OR 0.99, 95% CI: 0.60-1.62, P-value 0.97) were not significantly improved by UF treatment. Conclusions UF is associated with significant improvements in clinical decongestion but not in rates of re-hospitalization or mortality.

OBESITY IS ASSOCIATED WITH LOWER MORTALITY FOLLOWING ACUTE CORONARY SYNDROMES: A META-ANALYSIS

Higher Body Mass Index (BMI) is associated with decreased mortality in heart failure patients; a phenomenon termed the ‘Obesity Paradox’. This meta-analysis aims to evaluate BMI (kg/m2) as a predictor of 1-year mortality in patients with acute coronary syndromes (ACS). We searched MEDLINE using