Calcium antagonists and myocardial protection

Cardiovascular effects of diesel exhaust inhalation: photochemically altered versus freshly emitted in mice

This study was designed to compare the cardiovascular effects of inhaled photochemically altered diesel exhaust (aged DE) to freshly emitted DE (fresh DE) in female C57Bl/6 mice. Mice were exposed to either fresh DE, aged DE, or filtered air (FA) for 4 hr using an environmental irradiation chamber. Cardiac responses were assessed 8 hr after exposure utilizing Langendorff preparation with a protocol consisting of 20 min of perfusion and 20 min of ischemia followed by 2 hr of reperfusion. Cardiac function was measured by indices of left-ventricular-developed pressure (LVDP) and contractility (dP/dt) prior to ischemia. Recovery of post-ischemic LVDP was examined on reperfusion following ischemia. Fresh DE contained 460 µg/m³ of particulate matter (PM), 0.29 ppm of nitrogen dioxide (NO₂) and no ozone (O₃), while aged DE consisted of 330 µg/m³ of PM, 0.23 ppm O₃ and no NO₂. Fresh DE significantly decreased LVDP, dP/dt_max, and dP/dt_min compared to FA. Aged DE also significantly reduced LVDP and dP/dt_max. Data demonstrated that acute inhalation to either fresh or aged DE lowered LVDP and dP/dt, with a greater fall noted with fresh DE, suggesting that the composition of DE may play a key role in DE-induced adverse cardiovascular effects in female C57Bl/6 mice.

Photochemically altered air pollution mixtures and contractile parameters in isolated murine hearts before and after ischemia

BACKGROUND

The cardiopulmonary effects of the individual criteria air pollutants have been well investigated, but little is known about the cardiopulmonary effects of inhaled multipollutant mixtures that more realistically represent environmental exposures.

OBJECTIVES

We assessed the cardiopulmonary effects of exposure to photochemically altered particle-free multipollutant mixtures.

METHODS

We exposed mice to filtered air (FA), multipollutant mixtures, or ozone (O3) for 4 hr in a photochemical reaction chamber. Eight hours after exposure, we assessed cardiac responses using a Langendorff preparation in a protocol consisting of 20 min of global ischemia followed by 2 hr of reperfusion. Cardiac function was assessed by measuring the index of left-ventricular developed pressure (LVDP) and contractility (dP/dt) before ischemia. On reperfusion after ischemia, recovery of postischemic LVDP and size of infarct were examined. We used bronchoalveolar lavage (BAL) cell counts to assess lung inflammation.

RESULTS

Exposure to the multipollutant mixtures decreased LVDP, baseline rate of left ventricular contraction (dP/dtmaximum), and baseline rate of left ventricular relaxation (dP/dtminimum) compared with exposure to FA. Exposure to O3 also decreased heart rate and dP/dtminimum. Time to ischemic contracture was prolonged in the multipollutant-mixture group relative to that in the FA group. Mice in the multipollutant-mixture group had better recovery of postischemic LVDP and smaller infarct size. Exposure to multipollutant mixtures and to O3 exposure increased numbers of macrophages in the BAL fluid.

CONCLUSIONS

Exposure to photochemically altered urban air pollution appears to affect cardiac mechanics in isolated perfused hearts. Inhalation of acute multipollutant mixtures decreases LVDP and cardiac contractility in isolated non-ischemic murine hearts, prolongs ischemic contracture, increases postischemic recovery of LVDP, and reduces infarct size.

Massive diltiazem overdose treated with extracorporeal membrane oxygenation

OBJECTIVE

To describe a case of massive diltiazem overdose with a good outcome achieved after early and aggressive supportive therapy.

DESIGN

Case report.

SETTING

Pediatric Critical Care Unit.

PATIENT

Sixteen-year-old adolescent girl.

MEASUREMENTS AND MAIN RESULTS

A 16-yr-old adolescent girl presented to the emergency department 6 hrs after the intentional ingestion of 40 300-mg sustained-release diltiazem tablets (12 g of Cardura CD). She was hypotensive and required a glucagon and epinephrine infusion despite initial fluid resuscitation with saline and intravenous calcium (1 g). Multiple asystolic cardiac arrests ensued which became increasingly refractory to high-dose epinephrine. Hemodynamic support was achieved with a 48-hr period of extracorporeal membrane oxygenation for atrial standstill. Severe multiorgan dysfunction ensued (cardiac, neurologic, renal, hepatic, gastrointestinal, hematologic, and metabolic). Plasma diltiazem and its metabolites were measured and its half-life was reported between 28 and 48 hrs. A sustained decline in plasma diltiazem levels and its metabolites was not observed after two periods of charcoal hemoperfusion. Recovery of organ function occurred with sinus rhythm noted on the ninth day. The patient made a full recovery and was discharged from the critical care unit after 15 days.

CONCLUSIONS

Although massive calcium channel blocker overdose can produce profound and prolonged cardiac or multiorgan dysfunction, its toxic effects may be reversible. Supportive therapy, particularly of the cardiovascular system, is the most important goal.

Calcium antagonists and left ventricular dysfunction

Calcium antagonists are used in the management of a variety of cardiovascular disorders. Ischemia leads to left ventricular dysfunction, which is the clinical entity on which the calcium antagonists are expected to have their effect as a result of their anti-ischemic action. This article reviews the efficacy of calcium antagonists in several different settings of left ventricular dysfunction due to ischemia and reperfusion.