Magnesium and cardiovascular disease

Understanding the mechanistic roles of microplastics combined with heavy metals in regulating ferroptosis: Adding new paradigms regarding the links with diseases

As a new type of pollutant, microplastics (MPs) commonly exist in today's ecosystems, causing damage to the ecological environment and the health of biological organisms, including human beings. MPs can function as carriers of heavy metals (HMs) to aggravate the enrichment of HMs in important organs of organisms, posing a great threat to health. Ferroptosis, a novel process for the regulation of nonapoptotic cell death, has been shown to be closely related to the occurrence and processes of MPs and HMs in diseases. In recent years, some HMs, such as cadmium (Cd), iron (Fe), arsenic (As) and copper (Cu), have been proven to induce ferroptosis. MPs can function as carriers of HMs to aggravate damage to the body. This damage involves oxidative stress, mitochondrial dysfunction, lipid peroxidation (LPO), inflammation, endoplasmic reticulum stress (ERS) and so on. Therefore, ferroptosis has great potential as a therapeutic target for diseases induced by MPs combined with HMs. This paper systematically reviews the potential effects and regulatory mechanisms of MPs and HMs in the process of ferroptosis, focusing on the mitochondrial damage, Fe accumulation, LPO, ERS and inflammation caused by MPs and HMs that affect the regulatory mechanism of ferroptosis, providing new insights for research on regulating drugs and for the development of ferroptosis-targeting therapy for Alzheimer's disease, Parkinson's disease, cancer and cardiovascular disease.

Effect of Magnesium on Ventricular Extrasystoles in Children

Magnesium (Mg) is a crucial element for cardiovascular system and its deficiency results in a variety of cardiac arrhythmias. The aim of this study is to determine the effect of oral Mg supplementation on the frequency of ventricular extrasystoles (VES) in children. Magnesium supplementation was given to 42 children who had VES without structural heart disease. Clinical, electrocardiographic, and Holter monitoring studies were reviewed. The mean baseline 24 h VES burden on Holter monitoring was 10.26% ± 4.13% and it was decreased to 6.62% ± 3.88% after. There was no significant difference between the pre-treatment serum Mg levels and the decrease in the frequency of VES. In conclusion, oral Mg therapy was found to be effective at suppressing VES in children regardless of serum Mg levels. Large and randomized studies are needed to demonstrate the effect of magnesium on VES suppression.

Electrolyte monitoring during regional citrate anticoagulation in continuous renal replacement therapy

Patients with acute kidney injury who need continuous renal replacement therapy with locoregional citrate anticoagulation are at risk of citrate accumulation with disruption of the calcium balance. We aimed to evaluate the safety of detecting citrate accumulation and adjusting electrolyte disbalances during continuous venovenous hemodialysis (CVVHD) in critically ill patients with acute kidney injury using a blood sample frequency every 6 h. A prospective single center study in critically ill intensive care unit patients who suffered from acute kidney injury with the need of renal replacement therapy. We evaluated the deviations in pH, bicarbonate and calcium during CVVHD treatment with local regional citrate anticoagulation. Values indicate median and interquartile range. Severe hypocalcemia (below 1.04 mmol/L) or hypercalcemia (above 1.31 mmol/L) occurred in 10.5% and 4.8% respectively. During treatment changes of systemic ionized calcium, post-filter ionized calcium, pH and bicarbonate were corrected with protocolized adjustments. No arrhythmias or citrate accumulation were seen. The values stabilized after 42 h and after that no statistically significant changes were observed. After 42 h of citrate CVVHD, systemic ionized calcium, pH and bicarbonate levels stabilized. A blood sample frequency every 6 h is probably safe to detect citrate accumulation and to adjust the settings of electrolytes to avoid serious electrolyte disturbances in ICU patients without severe metabolic acidosis or severe liver failure.

Cardiac Arrest Associated with Combination Cisapride and Itraconazole Therapy

We report a case of cardiac arrest associated with cisapride in combination with itraconazole and provide a brief review of pertinent literature. Cisapride (Propulsid; Janssen Pharmaceuticals, Titusville, NJ), a gastrointestinal prokinetic drug, has recently been reported to prolong the QT interval. Itraconazole, an oral antifungal agent, is an inhibitor of cytochrome P450 (CYP3A4) metabolism and may elevate serum drug levels of compounds metabolized by this pathway. A 31-year-old woman had a witnessed cardiac arrest while taking the combination of cisapride and itraconazole. Following resucitation, the prolonged QT interval returned to normal after withdrawal of both agents. Echocardiography and cardiac catheterization were within normal limits; electrophysiologic testing failed to induce ventricular tachycardia/ventricular fibrillation. She has had no documented arrhythmias since the arrest. This combination can now be added to a growing list of drugs that may cause torsades de pointes and sudden cardiac death.

Magnesium Replacement to Protect Cardiovascular and Kidney Damage? Lack of Prospective Clinical Trials

Patients with advanced chronic kidney disease exhibit an increase in cardiovascular mortality. Recent works have shown that low levels of magnesium are associated with increased cardiovascular and all-cause mortality in hemodialysis patients. Epidemiological studies suggest an influence of low levels of magnesium on the occurrence of cardiovascular disease, which is also observed in the normal population. Magnesium is involved in critical cellular events such as apoptosis and oxidative stress. It also participates in a number of enzymatic reactions. In animal models of uremia, dietary supplementation of magnesium reduces vascular calcifications and mortality; in vitro, an increase of magnesium concentration decreases osteogenic transdifferentiation of vascular smooth muscle cells. Therefore, it may be appropriate to evaluate whether magnesium replacement should be administered in an attempt to reduce vascular damage and mortality in the uremic population In the present manuscript, we will review the magnesium homeostasis, the involvement of magnesium in enzymatic reactions, apoptosis and oxidative stress and the clinical association between magnesium and cardiovascular disease in the general population and in the context of chronic kidney disease. We will also analyze the role of magnesium on kidney function. Finally, the experimental evidence of the beneficial effects of magnesium replacement in chronic kidney disease will be thoroughly described.

Effects of IL-33/ST2 pathway in acute inflammation on tissue damage, antioxidative parameters, magnesium concentration and cytokines profile

AIM

The aim of this study was to examine the role of IL-33/ST2 pathway in a pathogenesis of acute inflammation and its effects on tissue damage, antioxidative capacity, magnesium concentration and cytokine profile in acutely inflamed tissue.

MATERIAL AND METHODS

Male mice were randomly divided in four groups: wild-type control group (WT-C), ST2 knockout control group (KO-C), wild-type inflammatory group (WT-I), and ST2 knockout inflammatory group (KO-I). Acute inflammation was induced in WT-I and KO-I by intramuscular injection of turpentine oil, while mice in WT-C and KO-C were treated with saline. After 12h, animals were euthanized, and blood was collected for determination of creatine kinase (CK) and aspartate transaminase (AST) activity. The treated tissue was used for histopathological analysis, determination of volume density of inflammatory infiltrate (Vdii) and necrotic fiber (Vdnf), gene expression of interleukin (IL)-33, ST2, tumor necrosis factor alpha (TNF-alpha), IL-6, IL-12p35, and transforming growth factor beta (TGF-beta), concentration of magnesium (Mg), copper (Cu), selenium (Se), manganese (Mn) and reduced glutathione (GSH), and superoxide dismutase (SOD) and glutathione peroxidase (GPx) activity.

RESULTS

Presence of inflammatory infiltration and necrosis in the treated tissue was histopathologically confirmed in WT-I and KO-I. Vdii was significantly higher in WT-I when compared to KO-I, whereas Vdnf did not significantly differ between WT-I and KO-I. CK and AST significantly increased in both inflammatory groups when compared to corresponding control groups. However, the values of CK and AST were significantly higher in WT-I than in KO-I. Mg in the treated tissue was significantly lower in WT-I in comparison to WT-C and KO-I, while there was no significant difference between KO-C and KO-I. There was no significant difference in Cu, Se, and Mn in the treated tissue between WT-C, KO-C, WT-I and KO-I. Gene expression of IL-33 in the treated tissue increased in both inflammatory groups when compared to the corresponding control groups, but it was significantly higher in KO-I than in WT-I. Gene expression of ST2 in the treated tissue was significantly higher in WT-I than in WT-C. Gene expression of TNF-alpha, IL-6, and IL-12p35 in the treated tissue was significantly higher in WT-I and KO-I than in the corresponding control groups, and IL-6 was significantly higher in KO-C than in WT-C. TGF-beta gene expression in the treated tissue was significantly higher in KO-I when compared to WT-I, while there was no difference between WT-C and KO-C. SOD activity decreased at the site of acute inflammation in both inflammatory groups, while the GPx activity increased. GSH in the treated tissue was significantly higher in KO-I than in KO-C or WT-I.

CONCLUSION

The results of our study have indicated, to our knowledge for the first time, that IL-33/ST2 pathway plays a role in enhancing inflammation and tissue damage at the site of acute inflammation by affecting the concentration of magnesium and GSH, important for antioxidative capacity, as well as gene expression of anti-inflammatory cytokine TGF-beta.

Late outcome of a randomized study on oral magnesium for premature complexes

Background

Ventricular and supraventricular premature complexes (PC) are frequent and usually symptomatic. According to a previous study, magnesium pidolate (MgP) administration to symptomatic patients can improve the PC density and symptoms.

Objective

To assess the late follow-up of that clinical intervention in patients treated with MgP or placebo.

Methods

In the first phase of the study, 90 symptomatic and consecutive patients with PC were randomized (double-blind) to receive either MgP or placebo for 30 days. Monthly follow-up visits were conducted for 15 months to assess symptoms and control electrolytes. 24-hour Holter was performed twice, regardless of symptoms, or whenever symptoms were present. In the second phase of the study, relapsing patients, who had received MgP or placebo (crossing-over) in the first phase, were treated with MgP according to the same protocol.

Results

Of the 45 patients initially treated with MgP, 17 (37.8%) relapsed during the 15-month follow-up, and the relapse time varied. Relapsing patients treated again had a statistically significant reduction in the PC density of 138.25/hour (p < 0.001). The crossing-over patients reduced it by 247/hour (p < 0.001). Patients who did not relapse, had a low PC frequency (3 PC/hour). Retreated patients had a 76.5% improvement in symptom, and crossing-over patients, 71.4%.

Conclusion

Some patients on MgP had relapse of symptoms and PC, indicating that MgP is neither a definitive nor a curative treatment for late follow-up. However, improvement in the PC frequency and symptoms was observed in the second phase of treatment, similar to the response in the first phase of treatment.

Modulation of cellular Mg2+ content in cardiac cells by α1-adrenoceptor stimulation and anti-arrhythmic agents

Magnesium (Mg²⁺) is used pharmacologically to sedate specific forms of arrhythmias. Administration of pharmacological doses of catecholamine or adrenergic receptor agonists often results in arrhythmias onset. Results from the present study indicate that stimulation of cardiac adrenergic receptors elicits an extrusion of cellular Mg²⁺ into the extracellular space. This effect occurs in both perfused hearts and isolated cells within 5-6 min following either β- or α₁-adrenergic receptor stimulation, and is prevented by specific adrenergic receptors antagonists. Sequential stimulation of the two classes of adrenergic receptor results in a larger mobilization of cellular Mg²⁺ provided that the two agonists are administered together or within 1-2 min from each other. A longer delay in administering the second stimulus results in the abolishment of Mg²⁺ extrusion. Hence, these data suggest that the stimulation of β- and α₁-adrenergic receptors mobilizes Mg²⁺ from two distinct cellular pools, and that Mg²⁺ loss from either pool triggers a Mg²⁺ redistribution within the cardiac myocyte. At the sarcolemmal level, Mg²⁺ extrusion occurs through a Na⁺/Mg²⁺ exchange mechanism phosphorylated by cAMP. Administration of quinidine, a patent anti-arrhythmic agent, blocks Na⁺ transport in a non-specific manner and prevents Mg²⁺ extrusion. Taken together, these data indicate that catecholamine administration induces dynamic changes in total and compartmentalized Mg²⁺ pools within the cardiac myocytes, and suggest that prevention of Mg²⁺ extrusion and redistribution may be an integral component of the effectiveness of quinidine and possibly other cardiac anti-arrhythmic agents. Confirmation of this possibility by future experimental and clinical studies might result in new patents of these compounds as Mg²⁺ preserving agents.

The in vitro digestibility and absorption of magnesium in some edible seaweeds

BACKGROUND

Many edible seaweeds are rich in magnesium (Mg). However, Mg absorption is low in some seaweeds because fibers in these seaweeds suppress Mg absorption. We hypothesize that Mg absorption from some other seaweeds is not low because of the diversity of fibers. We measured Mg concentration and Mg solubility after in vitro digestion in edible seaweeds, Aosa (Ulvaceae pertusa), Kombu (Laminaria japonica) and Funori (Gloiopeltis furcata). Then we determined Mg absorption in rats given diets containing these seaweeds or magnesium oxide as the major source of Mg, and calculated Mg absorption from seaweeds.

RESULTS

The fractional apparent absorption of Mg in seaweeds was Kombu = magnesium oxide > Aosa = Funori. Mg concentration was Aosa > Kombu and Funori had an intermediate amount of Mg, while Mg solubility after in vitro digestion was Funori = Kombu > Aosa. Consequently, the absorbable Mg concentration was Aosa = Kombu > Funori.

CONCLUSION

The absorption of Mg from different seaweeds differs and is not affected by the Mg solubility alone. The absorbable Mg concentration was high in Aosa and in Kombu, indicating that Aosa and Kombu are good sources of Mg.

Current pharmacological advances in the treatment of cardiac arrest

Cardiac arrest is defined as the sudden cessation of spontaneous ventilation and circulation. Within 15 seconds of cardiac arrest, the patient loses consciousness, electroencephalogram becomes flat after 30 seconds, pupils dilate fully after 60 seconds, and cerebral damage takes place within 90–300 seconds. It is essential to act immediately as irreversible damage can occur in a short time. Cardiopulmonary resuscitation (CPR) is an attempt to restore spontaneous circulation through a broad range of interventions which are early defibrillation, high-quality and uninterrupted chest compressions, advanced airway interventions, and pharmacological interventions. Drugs should be considered only after initial shocks have been delivered (when indicated) and chest compressions and ventilation have been started. During cardiopulmonary resuscitation, no specific drug therapy has been shown to improve survival to hospital discharge after cardiac arrest, and only few drugs have a proven benefit for short-term survival. This paper reviews current pharmacological treatment of cardiac arrest. There are three groups of drugs relevant to the management of cardiac arrest: vasopressors, antiarrhythmics, and other drugs such as sodium bicarbonate, calcium, magnesium, atropine, fibrinolytic drugs, and corticosteroids.

Role of Mg(2+) block of the inward rectifier K(+) current in cardiac repolarization reserve: A quantitative simulation

Different K(+) currents serve as "repolarization reserve" or a redundant repolarizing mechanism that protects against excessive prolongation of the cardiac action potential and therefore arrhythmia. Impairment of the inward rectifier K(+) current (I(K1)) has been implicated in the pathogenesis of cardiac arrhythmias. The characteristics of I(K1) reflect the kinetics of channel block by intracellular cations, primarily spermine (a polyamine) and Mg(2+), whose cellular levels may vary under various pathological conditions. However, the relevance of endogenous I(K1) blockers to the repolarization reserve is still not fully understood in detail. Here we used a mathematical model of a cardiac ventricular myocyte which quantitatively reproduces the dynamics of I(K1) block to examine the effects of the intracellular spermine and Mg(2+) concentrations, through modifying I(K1), on the action potential repolarization. Our simulation indicated that an I(K1) transient caused by relief of Mg(2+) block flows during early phase 3. Increases in the intracellular spermine/Mg(2+) concentration, or decreases in the intracellular Mg(2+) concentration, to levels outside their normal ranges prolonged action potential duration by decreasing the I(K1) transient. Moreover, reducing both the rapidly activating delayed rectifier current (I(Kr)) and the I(K1) transient caused a marked retardation of repolarization and early afterdepolarization because they overlap in the voltage range at which they flow. Our results indicate that the I(K1) transient caused by relief of Mg(2+) block is an important repolarizing current, especially when I(Kr) is reduced, and that abnormal intracellular free spermine/Mg(2+) concentrations may be a missing risk factor for malignant arrhythmias in I(Kr)-related acquired (drug-induced) and congenital long QT syndromes.

Pathophysiologic bases for adjunctive therapies in the treatment and secondary prevention of acute myocardial infarction

Postmyocardial infarction (MI) survival has been steadily improving. This improvement has been due, in part, to the actions of the adjunctive medical therapies for the treatment of MI. Aspirin, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, and lipid-lowering agents have been shown to improve survival in the treatment and secondary prevention of MI. Nitrates have beneficial effects as well. These medications complement the reperfusion strategies through different mechanisms. Other adjunctive medical therapies, namely magnesium, antiarrhythmic agents, and calcium-channel blockers, have not been shown to improve mortality with routine post-MI use despite their theoretical benefits.

Adjunctive therapy after reperfusion therapy in acute myocardial infarction

The current era has witnessed dramatic improvement in the treatment of acute myocardial infarction, due in large part to the more widespread use of thrombolytic therapy aimed at quickly restoring perfusion in the infarct-related artery. This review addresses the role of adjunctive pharmacologic therapy in the thrombolytic era, recognizing that much of the available clinical trial data supporting the role of adjunctive pharmacologic treatment strategies was conducted in patient populations not widely exposed to reperfusion therapy. This review, therefore, explores the data supporting the incremental benefit of therapy with beta blockers, nitrates, angiotensin-converting enzyme inhibitors, or magnesium in addition to thrombolytic therapy. Heparin and aspirin will not be discussed.

Hypermagnesemia predicts mortality in elderly with congestive heart disease: relationship with laxative and antacid use

The aim of this study was to evaluate the role of magnesium levels on 3-year survival in the elderly with congestive heart failure (CHF) admitted to the Rehabilitative Cardiology Unit of S. Maugeri Foundation Scientific Institute of Telese/Campoli. All elderly patients > or = 65 years old with a diagnosis of CHF underwent clinical and instrumental examination, and their demographics, co-morbidity, and in-hospital and 3-year mortality rates were recorded. Hypomagnesemia was found in 4.8%, normomagnesemia in 67.5%, and hypermagnesemia in 27.8% of subjects. The hypomagnesemic group was excluded for numerical exiguity; the analysis was performed on a total of 199 elderly patients. Hypermagnesemia was found in 29.1% and normomagnesemia in 70.9%. At the univariate analysis no differences were found in hypermagnesemia in respect to normomagnesemia group, except for slightly higher levels of creatininemia (1.35 +/- 0.61 vs. 1.13 +/- 0.55 mg/dL, respectively; p < 0.02), greater disability (lost ADL, 2.69 +/- 1.57 vs. 2.15 +/- 1.56, respectively; p < 0.05), more mortality for CHF (32.6 vs. 48.3%; p < 0.05), and higher antacid and laxative use (82.7 vs. 24.8%, respectively; p < 0.0001). Patients with higher magnesium showed less probability to survive at a 3-year follow-up than did patients with lower levels (17.32 +/- 15.93 vs. 22.46 +/- 16.16 months; p < 0.05), and this finding remained significant in the multivariate analysis after adjusting for some confounders. Finally hypermagnesemia should also be considered in the absence of pre-existing renal failure clinical evidence because of its negative prognostic value, especially in elderly patients with CHF. The shown relationship between hypermagnesemia and laxative/antacid use should induce physicians to pay more attention to abuse of these drugs.

Successful uses of magnesium sulfate for torsades de pointes in children with long QT syndrome

BACKGROUND

Administration of magnesium sulfate (MgSO4) is an effective and safe treatment for torsades de pointes (TdP) associated with acquired long QT syndrome (LQTS) in adults. As for children, there are few reports focusing on it. The authors discuss the efficacy of MgSO4 for TdP in children with congenital and acquired LQTS. The authors also discuss the optimal administration dosage and serum magnesium (SMg) concentration during MgSO4 therapy.

METHODS

The authors studied seven consecutive LQTS children undergoing MgSO4 therapy for TdP. Of the seven children, five were congenital LQTS and two were acquired LQTS. A bolus injection of MgSO4 was given intravenously over 1-2 min followed by continuous infusion for the next 2-7 days.

RESULTS

Of the seven patients, six responded completely to the initial bolus. The bolus dosage was 5.9 +/- 3.8 mg/kg (range, 2.3-12 mg/kg) in these six, and the other remaining one (neonate with congenital LQTS) required a total of 30 mg/kg until complete abolishment. The continuous infusion was given at rates of 0.3-1.0 mg/kg per h and patients did not show recurrence of TdP. The SMg concentration was 3.9 +/- 1.0 mg/dL (2.9-5.4 mg/dL) immediately after bolus injection. The mean corrected QT (QTc) interval before and after bolus injection did not show significant difference.

CONCLUSION

Intravenous infusion of MgSO4 was effective for TdP in children with LQTS, and MgSO4 abolished TdP without shortening the QTc interval. The optimal bolus dosage, infusion rates and SMg concentration were 3-12 mg/kg, 0.5-1.0 mg/kg per h and 3-5 mg/dL, respectively.

The Road to Bioabsorbable Stents: Reaching Clinical Reality?

This article provides an overview of the evolution of revascularization devices since Grüntzig's initial introduction of balloon angioplasty in 1977. In-stent restenosis (ISR) is the major shortcoming of conventional (permanent-implant) stent therapy; even with the innovation and promising benefits of drug-eluting stents, management of ISR is very difficult. ISR is mainly caused by the interaction between the blood and the stent surface and a permanent mechanical irritation of the vascular tissue. Thus stenting technology has moved toward the development of temporary implants composed of biocompatible materials which mechanically support the vessel during the period of high risk for recoil and then completely biodegrade in the long term. Preclinical and first clinical experiences with bioabsorbable magnesium stents are discussed.

Severe electrolyte disorders following cardiac surgery: a prospective controlled observational study

Introduction

Electrolyte disorders are an important cause of ventricular and supraventricular arrhythmias as well as various other complications in the intensive care unit. Patients undergoing cardiac surgery are at risk for development of tachyarrhythmias, especially in the period during and immediately after surgical intervention. Preventing electrolyte disorders is thus an important goal of therapy in such patients. However, although levels of potassium are usually measured regularly in these patients, other electrolytes such as magnesium, phosphate and calcium are measured far less frequently. We hypothesized that patients undergoing cardiac surgical procedures might be at risk for electrolyte depletion, and we therefore conducted the present study to assess electrolyte levels in such patients.

Methods

Levels of magnesium, phosphate, potassium, calcium and sodium were measured in 500 consecutive patients undergoing various cardiac surgical procedures who required extracorporeal circulation (group 1). A total of 250 patients admitted to the intensive care unit following other major surgical procedures served as control individuals (group 2). Urine electrolyte excretion was measured in a subgroup of 50 patients in both groups.

Results

All cardiac patients received 1 l cardioplegia solution containing 16 mmol potassium and 16 mmol magnesium. In addition, intravenous potassium supplementation was greater in cardiac surgery patients (mean ± standard error: 10.2 ± 4.8 mmol/hour in cardiac surgery patients versus 1.3 ± 1.0 in control individuals; P < 0.01), and most (76% versus 2%; P < 0.01) received one or more doses of magnesium (on average 2.1 g) for clinical reasons, mostly intraoperative arrhythmia. Despite these differences in supplementation, electrolyte levels decreased significantly in cardiac surgery patients, most of whom (88% of cardiac surgery patients versus 20% of control individuals; P < 0.001) met criteria for clinical deficiency in one or more electrolytes. Electrolyte levels were as follows (mmol/l [mean ± standard error]; cardiac patients versus control individuals): phosphate 0.43 ± 0.22 versus 0.92 ± 0.32 (P < 0.001); magnesium 0.62 ± 0.24 versus 0.95 ± 0.27 (P < 0.001); calcium 1.96 ± 0.41 versus 2.12 ± 0.33 (P < 0.001); and potassium 3.6 ± 0.70 versus 3.9 ± 0.63 (P < 0.01). Magnesium levels in patients who had not received supplementation were 0.47 ± 0.16 mmol/l in group 1 and 0.95 ± 0.26 mmol/l in group 2 (P < 0.001). Urinary excretion of potassium, magnesium and phosphate was high in group 1 (data not shown), but this alone could not completely account for the observed electrolyte depletion.

Conclusion

Patients undergoing cardiac surgery with extracorporeal circulation are at high risk for electrolyte depletion, despite supplementation of some electrolytes, such as potassium. The probable mechanism is a combination of increased urinary excretion and intracellular shift induced by a combination of extracorporeal circulation and decreased body temperature during surgery (hypothermia induced diuresis). Our findings may partly explain the high risk of tachyarrhythmia in patients who have undergone cardiac surgery. Prophylactic supplementation of potassium, magnesium and phosphate should be seriously considered in all patients undergoing cardiac surgical procedures, both during surgery and in the immediate postoperative period. Levels of these electrolytes should be monitored frequently in such patients.

Acquired QT interval prolongation and HERG: implications for drug discovery and development

Putative interactions between the Human Ether-a-go-go Related Gene (HERG), QT interval prolongation and Torsades de Pointes (TdP) are now integral components of any discussion on drug safety. HERG encodes for the inwardly rectifying potassium channel (I(Kr)), which is essential to the maintenance of normal cardiac function. HERG channel mutations are responsible for one form of familial long QT syndrome, a potentially deadly inherited cardiac disorder associated with TdP. Moreover, drug-induced (acquired) QT interval prolongation has been associated with an increase in the incidence of sudden unexplained deaths, with HERG inhibition implicated as the underlying cause. Subsequently, a number of non-cardiovascular drugs which induce QT interval prolongation and/or TdP have been withdrawn. However, a definitive link between HERG, QT interval prolongation and arrhythmogenesis has not been established. Nevertheless, this area is subject to ever increasing regulatory scrutiny. Here we review the relationship between HERG, long QT syndrome and TdP, together with a summary of the associated regulatory issues, and developments in pre-clinical screening.

Dietary magnesium intake and the future risk of coronary heart disease (the Honolulu Heart Program)

Magnesium (Mg) deficiency is believed to have adverse cardiovascular consequences that are broad and complex, although an association between dietary Mg intake and the risk of coronary heart disease (CHD) has not been clearly identified. The purpose of this study is to examine the relation between dietary Mg intake and future risk of CHD. Reported findings are based on dietary Mg intake in 7,172 men in the Honolulu Heart Program. Intake of Mg was recorded at baseline examinations that took place from 1965 to 1968 when the men were aged 45 to 68 years. In 30 years of follow-up, 1,431 incident cases of CHD were identified. Within 15 years after dietary assessment, the age-adjusted incidence decreased significantly from 7.3 to 4.0 per 1,000 person-years in the lowest (50.3 to 186 mg/day) versus highest (340 to 1,183 mg/day) quintiles of Mg intake (p <0.001). When adjustments were made for age and other nutrients (singly or combined), there was a 1.7- to 2.1-fold excess in the risk of CHD in the lowest versus highest quintiles (p <0.001). The excess risk ranged from 1.5- to 1.8-fold after further adjustment for other cardiovascular risk factors (p <0.05). Associations between dietary Mg and coronary events occurring after 15 years of follow-up were modest. We conclude that the intake of dietary Mg is associated with a reduced risk of CHD. Whether increases in dietary Mg intake can alter the future risk of disease warrants further study.

Dietary minerals and modification of cardiovascular risk factors

High serum cholesterol, hypertension and obesity are major risk factors for cardiovascular diseases, and together with insulin resistance form a deadly disorder referred to as the metabolic syndrome. All the aspects of this syndrome are strongly related to dietary and lifestyle factors; therefore, it would be reasonable to look for dietary approaches to their modification. Mineral nutrients, such as calcium, potassium and magnesium, lower blood pressure, and especially calcium has beneficial effects also on serum lipids. Recent evidence suggests that increased intake of calcium may help in weight control as well. This review summarizes previous literature on the effects and use of dietary minerals on serum lipids, blood pressure and obesity, with specific focus on the effects of calcium. Calcium and magnesium as divalent cations can form insoluble soaps with fatty acids in the intestine and thus prevent the absorption of part of the dietary fat. Decreased absorption of saturated fat leads to reduction in serum cholesterol level via decreased production of VLDL and increased intake of LDL in the liver. Dietary calcium may also bind bile acids, which increases the conversion of cholesterol to bile acids in the liver. Furthermore, calcium appears to enhance the cholesterol-lowering effect of plant sterols. Thus, dietary combination of the mineral nutrients and plant sterols provides a promising novel approach to the modification of cardiovascular risk factors.

Psychotropic drugs, cardiac arrhythmia, and sudden death

A variety of drugs targeted towards the central nervous system are associated with cardiac side effects, some of which are linked with reports of arrhythmia and sudden death. Some psychotropic drugs, particularly tricyclic antidepressants (TCAs) and antipsychotic agents, are correlated with iatrogenic prolongation of the QT interval of the electrocardiogram (ECG). In turn, this is associated with the arrhythmia (TdP). This review discusses the association between psychotropic agents, arrhythmia and sudden death and, focusing on TCAs and antipsychotics, considers their range of cellular actions on the heart; potentially pro-arrhythmic interactions between psychotropic and other medications are also considered. At the cellular level TCAs, such as imipramine and amitriptyline, and antipsychotics, such as thioridazine, are associated with inhibition of potassium channels encoded by In many cases this cellular action correlates with ECG changes and a risk of TdP. However, not all psychotropic agents that inhibit HERG at the cellular level are associated equally with QT prolongation in patients, and the potential for QT prolongation is not always equally correlated with TdP. Differences in risk between classes of psychotropic drugs, and between individual drugs within a class, may result from additional cellular effects of particular agents, which may influence the consequent effects of inhibition of repolarizing potassium current.

Does magnesium have a role in the treatment of patients with coronary artery disease?

Hypomagnesemia is common in hospitalized patients, especially in elderly patients with coronary artery disease (CAD) and/or those with chronic heart failure. Hypomagnesemia is associated with increased all cause mortality and mortality from CAD. Magnesium supplementation improves myocardial metabolism, inhibits calcium accumulation and myocardial cell death; it improves vascular tone, peripheral vascular resistance, afterload and cardiac output, reduces cardiac arrhythmias and improves lipid metabolism. Magnesium also reduces vulnerability to oxygen-derived free radicals, improves endothelial function and inhibits platelet function, including platelet aggregation and adhesion, which potentially confers upon magnesium physiologic and natural effects similar to adenosine-diphosphate inhibitors such as clopidogrel. However, data regarding the use of magnesium in patients with acute myocardial infarction (AMI) are conflicting. Although some previous relatively small randomized clinical trials demonstrated a remarkable reduction in mortality when intravenous magnesium was administered to relatively high risk AMI patients, two recently published large-scale randomized clinical trials (the Fourth International Study of Infarct Survival [ISIS 4] and Magnesium in Coronaries [MAGIC]) were unable to demonstrate any advantage of intravenous magnesium over placebo. Nevertheless, the theoretical benefits of magnesium supplementation as a cardio-protective agent in CAD patients, promising results from animal and human studies, its relatively low-cost and ease of handling requiring no special expertise, together with its excellent tolerability, gives magnesium a place in treating CAD patients, especially in those at high risk, such as CAD patients with heart failure, the elderly and hospitalized patients with hypomagnesemia. Furthermore, magnesium therapy is indicated in life-threatening ventricular arrhythmias such as torsades de pointes and intractable ventricular tachycardia.

Magnesium sulfate therapy after aneurysmal subarachnoid hemorrhage

OBJECT

Vasospasm remains a significant source of neurological morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH), despite advances in current medical, surgical, and endovascular therapies. Magnesium sulfate therapy has been demonstrated to be both safe and effective in preventing neurological complications in obstetrical patients with eclampsia. Evidence obtained using experimental models of brain injury, cerebral ischemia, and SAH indicate that Mg may also have a role as a neuroprotective agent. The authors hypothesize that MgSO4 therapy is safe, feasible, and has a beneficial effect on vasospasm and, ultimately, on neurological outcome following aneurysmal SAH.

METHODS

A prospective randomized single-blind clinical trial of high-dose MgSO4 therapy following aneurysmal SAH (Hunt and Hess Grades II-IV) was performed in 40 patients, who were enrolled within 72 hours following SAH and given intravenous MgSO4 or control solution for 10 days. Serum Mg++ levels were maintained in the 4 to 5.5 mg/dl range throughout the treatment period. Clinical management principles were the same between groups (including early use of surgery or endovascular treatment, followed by aggressive vasospasm prophylaxis and treatment). Daily transcranial Doppler (TCD) ultrasonographic recordings were obtained, and clinical outcomes were measured using the Glasgow Outcome Scale (GOS). The patients' GOS scores and the TCD recordings were analyzed using the independent t-test. Forty patients were enrolled in the study: 20 (15 female and five male patients) received treatment and 20 (11 female and nine male patients) comprised a control group. The mean ages of the patients in these groups were 46 and 51, respectively, and the mean clinical Hunt and Hess grades were 2.6 +/- 0.68 in the MgSO4 treatment group and 2.3 +/- 0.73 in the control group (mean +/- standard deviation [SD], p = 0.87). Fisher grades were similar in both groups. Mean middle cerebral artery velocities were 93 +/- 27 cm/second in MgSO4-treated patients and 102 +/- 34 cm/second in the control group (mean +/- SD, p = 0.41). Symptomatic vasospasm, confirmed by angiography, occurred in six of 20 patients receiving MgSO4 and in five of 16 patients receiving placebo. Mean GOS scores were 3.8 +/- 1.6 and 3.6 +/- 1.5 (mean +/- SD, p = 0.74) in the treatment and control groups, respectively. Significant adverse effects from treatment with MgSO4 did not occur.

CONCLUSIONS

Administration of high-dose MgSO4 following aneurysmal SAH is safe, and steady Mg++ levels in the range of 4 to 5.5 mg/dl are easily maintained. This treatment does not interfere with neurological assessment, administration of anesthesia during surgery, or other aspects of clinical care. We observed a trend in which a higher percentage of patients obtained GOS scores of 4 or 5 in the group treated with MgSO4, but the trend did not reach a statistically significant level. A larger study is needed to evaluate this trend further.

Cardioprotection: emerging pharmacotherapy

By the year 2020, it is predicted that acute coronary occlusion will be the major cause of death in the world. Recent advances in reperfusion therapy have substantially improved survival of patients with acute coronary syndromes. While early reperfusion reduces mortality, a time limitation exists with regard to myocardial salvage. In fact, the major limiting factor in further improving survival of patients with myocardial ischaemia is the susceptibility of the cardiomyocyte to ischaemic insult and lethal cell injury. Over the last decade substantial progress has been made in our understanding of the fundamental mechanisms of ischaemia/reperfusion injury. From this work novel means which limit or delay myocyte death have emerged and are currently under development as therapeutic candidates for the management of acute coronary syndromes. This report examines cardioprotective mechanisms and reviews clinical evidence for myocardial protective therapies.

Hypomagnesemic disorders

Adequate magnesium stores are vitally important for life. Critically ill patients will almost always have diminished levels of circulating magnesium, and this predisposes them to a variety of adverse effects, some life threatening. The causes of hypomagnesemia are many and varied, but in the critically ill, losses from the kidneys, often secondary to medications and from the gastrointestinal (GI) tract, predominate. The measurement of magnesium is not straightforward, although many clinicians are now switching to the use of ionized magnesium from ion selective electrodes. The use of supplemental magnesium in acute flares of asthma has some support in medical literature, especially for those patients with severe disease who fail traditional therapy. Magnesium holds the preeminent position in the treatment of pre-eclampsia and eclampsia in the minds of most obstetricians, who have decades of experience showing it to be both effective and safe. Magnesium is clearly useful for certain types of ventricular tachycardia, and probably assists in the treatment of several types of supraventricular tachycardia. Its role in acute myocardial ischemia is less certain, although there is no benefit once reperfusion therapy has already been carried out. Finally, the role of magnesium in the treatment of acute cerebral insults is an exciting area of active investigation with initial studies suggesting much promise.

Dietary potassium and magnesium supplementation in cyclosporine-induced hypertension and nephrotoxicity

BACKGROUND

Cyclosporine A (CsA)-induced hypertension and nephrotoxicity are aggravated by high sodium intake. Accumulating evidence suggests that potassium and magnesium supplementation could protect against the detrimental effects of dietary salt. In the present study, we tested the hypothesis of whether concurrent supplementation with potassium and magnesium could protect against the development of CsA-induced hypertension and nephrotoxicity more effectively than supplementation with one mineral alone.

METHODS

Eight-week-old spontaneously hypertensive rats (SHRs) were divided into four groups (N = 10 in each group): (1) CsA group (5 mg/kg subcutaneously) receiving high-sodium diet (Na 2.6%, K 0.8%, Mg 0.2% wt/wt); (2) CsA group receiving a high-sodium, high-potassium diet (Na 2.6%, K 2.4%, Mg 0.2%); (3) CsA group receiving high-sodium, high-magnesium diet (Na 2.6%, K 0.8%, Mg 0.6%); and (4) CsA group receiving high-sodium, high-potassium, high-magnesium diet (Na 2.6%, K 2.4%, Mg 0.6%).

RESULTS

CsA induced severe hypertension and deteriorated renal functions in SHRs on high-sodium diet. Histologically, the kidneys showed severe thickening of the media of the afferent artery with fibrinoid necrosis. Potassium supplementation lowered blood pressure (198 +/- 5 vs. 212 +/- 2 mm Hg, P < 0.05) and partially prevented the development of proteinuria (-25%, P < 0.05). Magnesium supplementation decreased blood pressure to the same extent but improved renal functions more effectively than potassium. The greatest protection against CsA toxicity was achieved when dietary potassium and magnesium supplementations were combined. Urinary N-acetyl-beta-D-glucosaminidase (NAG) excretion, a marker for renal proximal tubular damage, increased progressively in CsA-treated SHRs on the high-sodium diet. Neither potassium nor magnesium influenced urinary NAG excretion. We also estimated the activity of the renal dopaminergic system by measuring 24-hour urinary dopamine excretion rates. CsA suppressed the renal dopaminergic system during high-sodium diet. Magnesium supplementation, alone and in combination with potassium, protected against the development of renal dopaminergic deficiency in CsA-treated SHRs on high-sodium diet. Magnesium supplementation increased plasma-free ionized magnesium (iMg) and bone magnesium by 50 and 16%, respectively.

CONCLUSIONS

Our findings indicate that both potassium and magnesium supplementations showed beneficial effects against CsA-induced hypertension and nephrotoxicity. The protective effect of magnesium clearly exceeded that of potassium. The greatest protection against CsA toxicity was achieved when potassium and magnesium were combined. We also provide evidence that the development of CsA-induced glomerular, tubular, and vascular lesions are associated with renal dopaminergic deficiency.

Magnesium in drinking water in relation to morbidity and mortality from acute myocardial infarction

We investigated the importance of magnesium and calcium in drinking water in relation to morbidity and mortality from acute myocardial infarction. Cases were men and women 50-74 years of age living in 18 Swedish municipalities who had suffered an acute myocardial infarction some time between October 1, 1994, and June 30, 1996. Controls were randomly selected from the same study base. We interviewed the surviving cases (N = 823) and controls (N = 853), focusing on risk factors for acute myocardial infarction. We collected individual data on drinking water levels of magnesium and calcium. We classified subjects by quartile of water magnesium or calcium levels. The total number of cases was similar in the four quartiles. The risk of death was 7.6% (95% confidence interval = 2.1-13.1) lower in the quartile with high magnesium levels (> or = 8.3 mg/liter). The odds ratio for death from acute myocardial infarction in relation to water magnesium was 0.64 (95% confidence interval = 0.42-0.97) for the highest quartile relative to the three lower ones. Multivariate analyses showed that other risk factors were not important confounders. For calcium, this study was inconclusive. The data suggest that magnesium in drinking water is associated with lower mortality from acute myocardial infarction, but not with the total incidence.

Magnesium. An update on physiological, clinical and analytical aspects

There is an increased interest in the role of magnesium ions in clinical medicine, nutrition and physiology. The characteristics of the binding of magnesium and calcium ions to various components, macromolecules and biological membranes are described. Magnesium affects many cellular functions, including transport of potassium and calcium ions, and modulates signal transduction, energy metabolism and cell proliferation. The mechanism of cellular uptake and efflux of magnesium, its intracellular transport, intestinal absorption, renal excretion and the effect of hormones on these are reviewed. Magnesium deficiency is not uncommon among the general population: its intake has decreased over the years especially in the western world. The magnesium supplementation or intravenous infusion may be beneficial in various diseased states. Of special interest is the magnesium status in alcoholism, eclampsia, hypertension, atherosclerosis, cardiac diseases, diabetes, and asthma. The development of instrumentation for the assay of ionized magnesium is reviewed, as are the analytical procedures for total magnesium in blood and free magnesium in the cytosol. The improved procedures for the assay of different magnesium states are useful in understanding the role of magnesium in health and disease.

Magnesium repletion therapy improved lipid metabolism in hypomagnesemic renal transplant recipients: a pilot study

BACKGROUND

Hypomagnesemia has been associated with hypertension, abnormal glucose and lipid metabolism, and accelerated atherosclerosis in nontransplant patients.

METHODS

In this prospective short-term pilot study, 14 hypomagnesemic renal transplant recipients with stable renal function were evaluated monthly over a 6-month interval. The first 3 months was the baseline observation period. During the second 3 months, MgO2 was administered to normalize the serum Mg level. Glucose tolerance, lipid levels, blood pressure, weight, and routine chemistries were assessed before and after Mg replacement. All others medications were held constant during the 6-month study.

RESULTS

Serum Mg levels increased to normal range after MgO2 therapy, which was well tolerated. There were significant decreases in total cholesterol, low density lipoprotein, and total cholesterol/high density lipoprotein ratio after 3 months of MgO2 therapy. Only three patients had abnormal baseline glucose tolerance tests. All three patients showed improved glucose tolerance after MgO2, but this was not statistically significant.

CONCLUSIONS

Mg repletion may be an important ancillary therapy in hypomagnesemic renal transplant patients with hyperlipidemia.

Magnesium deficiency in adult rats promotes the induction of ventricular tachycardia by the administration of epinephrine

The effects of magnesium deficiency on epinephrine-induced ventricular tachyarrhythmia were investigated in adult rats. Forty-two adult Wistar rats were fed a magnesium-deficient diet while 30 rats were fed a standard diet for 20 days. The plasma magnesium concentration was lower in the magnesium-deficient rats (0.22+/-0.01 mmol/l) than in the control rats (0.76+/-0.03 mmol/l, P < 0.001). Using a telemetry system, electrocardiograms and arterial blood pressure were recorded on a polygraph in an unrestrained condition. Epinephrine was infused intravenously starting at 5 microg/kg per minute. The QT interval was prolonged to 50+/-1 ms in the magnesium-deficient rats compared with 44+/-1 ms in the control rats (P < 0.001). Before the administration of epinephrine, no ventricular tachyarrhythmias or seizures were found in either the control or the magnesium-deficient rats. The incidence of epinephrine-induced sustained ventricular tachycardia (VT) was higher in the magnesium-deficient rats (86%) than in the control rats (43%, P < 0.01). However, this VT did not result in sudden death. Seizures always preceded death in both the magnesium-deficient and control rats while the arrhythmias observed immediately before death were mainly bradyarrhythmias. The present study in an adult rat magnesium-deficient model revealed that magnesium deficiency enhances the susceptibility to epinephrine-induced ventricular tachyarrhythmias.

Cardiac management in the ICU

Coronary artery disease (CAD) is common in the surgical population, with up to 50% of postoperative deaths due to cardiac events. Most of these events are ischemic, with some being exacerbations of underlying congestive heart failure (CHF). Recent data indicate that acute perioperative beta-adrenergic blockade can reduce ischemia and ischemic events. Postoperative monitoring should focus on myocardial ischemia, with preparation for rapid treatment using IV therapy. A few studies suggest that elderly patients with known CAD undergoing major procedures might benefit from perioperative treatment guided by information from a pulmonary artery catheter. Postoperative CHF, which is likely to present early after surgery, may need aggressive management with diuretics, vasodilators, and inotropic drugs. Mechanical ventilation should be considered. When the patient develops severe or refractory dysrhythmias, serum magnesium levels should be supplemented and consideration given to IV use of amiodarone. Postoperative hypertension is common and can precipitate ischemia, CHF, and arrhythmias as well as cause bleeding. Newer IV drugs are arterial specific and can lower BP in a smooth and predictable manner. All acute cardiac disorders can be precipitated or exacerbated by inadequate pain control, hypoxemia, and fluid or electrolyte disorders.

Critical care cardiology

Emergency management of the patient with cardiac disease is an important part of veterinary practice. Although the causes of cardiac disease may be diverse, the understanding of basic pathophysiology will enable the clinician to formulate a rational diagnostic and therapeutic plan. The veterinary clinician must be able to triage the emergency patient, assess the clinical condition, and provide appropriate therapy. Close monitoring of the critically ill patient is crucial to patient survival and will help tailor therapy.

Is low magnesium concentration a risk factor for coronary heart disease? The Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

Hypomagnesemia has been hypothesized to play a role in coronary heart disease (CHD), but few prospective epidemiologic studies have been conducted.

METHODS AND RESULTS

We examined the relation of serum and dietary magnesium with CHD incidence in a sample of middle-aged adults (n=13,922 free of baseline CHD) from 4 US communities. Over 4 to 7 years of follow-up, 223 men and 96 women had CHD develop. After adjustment for sociodemographic characteristics, waist/hip ratio, smoking, alcohol consumption, sports participation, use of diuretics, fibrinogen, total and high-density lipoprotein cholesterol levels, triglyceride levels, and hormone replacement therapy, the relative risk of CHD across quartiles of serum magnesium was 1.00, 0.92, 0.48, and 0.44 (P for trend=0.009) among women and 1.00, 1.32, 0.95, and 0.73 (P for trend=0.07) among men. The adjusted relative risk of CHD for the highest versus the lowest quartile of dietary magnesium was 0.69 in men (95% confidence interval 0.45 to 1.05) and 1.32 in women (0.68 to 2.55).

CONCLUSIONS

These findings suggest that low magnesium concentration may contribute to the pathogenesis of coronary atherosclerosis or acute thrombosis.

Acute interventions for myocardial reperfusion

The primary goal of treatment in acute myocardial infarction is reperfusion of the infarct-related artery in as short a time as possible. Present strategies for acute reperfusion include the use of thrombolytic agents and a variety of catheter-based interventions. This article presents a brief review of these strategies and discusses the patient subsets better served by a particular type of intervention.

Pattern of cardiac fibrosis in rabbits periodically fed a magnesium-restricted diet and administered rare earth chloride through drinking water

It has been postulated that causation of the tropical cardiomyopathy endomyocardial fibrosis (EMF) is linked to magnesium (Mg) deficiency and cardiac toxicity of the rare earth element cerium (Ce). The aim of the present study was to define the myocardial lesions in rabbits that were fed on Mg-restricted diet (70-80 ppm) periodically and were provided drinking water contaminated with rare earth chloride (1 g/L). Forty New Zealand white rabbits were divided into four groups following a 2 x 2 factorial design. Two groups were periodically fed on Mg-restricted diet with one of them receiving water contaminated with rare earth chloride. The other two groups were continuously fed on Mg-sufficient diet (350-400 ppm) with one of them receiving water contaminated with rare earth chloride. All animals were sacrificed at the end of 6 mo. Cardiac tissues were subjected to histology, elemental analysis (calcium [Ca], Mg, and Ce) and estimation of collagen content and collagen phenotypes. Histological lesions were compared with those of EMF in humans and those of acute Mg deficiency in animals. The results suggest that in rabbits, recurrent episodes of Mg deficiency lead to myocardial fibrosis similar to the pattern observed in human EMF.

Hypomagnesemia in 188 dogs: a hospital population-based prevalence study

Magnesium is a divalent cation involved in more than 300 metabolic processes. Magnesium acts as an intracellular regulator of most energy-demanding pathways. Clinical investigation in the human medical field has determined risk factors for hypomagnesemia and its relationship to a number of disease processes. Experimental studies have established the effects of hypomagnesemia in dogs, but little is known of its prevalence, risk factors, or clinical associations in a hospital population of dogs. To study the prevalence, risk factors, and clinical associations of hypomagnesemia in dogs, a retrospective cross-sectional study of dogs admitted to the University of Minnesota Veterinary Teaching Hospital over a 2.5-year period was undertaken. The prevalence of hypomagnesemia in the study population was 6.1% (188 of 3,102 dogs). Using both categorical and continuous variables in a univariate analysis, significant associations with hypomagnesemia were identified and used to construct a multivariate analysis of the relative risk of hypomagnesemia. Results from evaluation of 3,102 dogs indicate that the most significant predictors of hypomagnesemia were albumin (P < or = .0001; odds ratio [OR] = 0.2), potassium (P < or = .0001; OR = 0.5), total CO2 (P < or = .05; OR = 0.9), and blood urea nitrogen concentrations (P < .0001; OR = 0.9), a diagnosis of cardiovascular disease (P < .02; OR = 1.9); and being a Collie (P < .02; OR = 3.9) or German Shepherd Dog (P < .002; OR = 2.2). These results can be used to better understand and predict hypomagnesemia in dogs.

Survey of trace elements in household and bottled drinking water samples collected in Riyadh, Saudi Arabia

Total dissolved beryllium (Be), cadmium (Cd), chromium (Cr), copper (Cu), iron (Fe), magnesium (Mg), manganese (Mn), mercury (Hg), nickel (Ni), selenium (Se), strontium (Sr), vanadium (V) and zinc (Zn) were measured in the drinking water of 101 households and 21 samples of retail bottled waters purchased in Riyadh, Saudi Arabia to ascertain the water quality for human consumption. The Inductively Coupled Plasma Spectrometer (ICP) was used for analysis. First-draw Fe, Mn, Ni and Zn concentrations decreased significantly after 10 min of flushing in the morning. Cd, Fe, Hg, Ni and Zn in some cases exceeded the guideline limits recommended by the EEC and WHO.

Hypocalcemia and hypomagnesemia

The occurrence of hypocalcemia is well documented in clinical veterinary medicine. In this article, we have attempted to provide an overview of the established causes as well as information on more recently recognized etiologies such as the ionized hypocalcemia seen in cats with urethral obstruction and the presence of the disorder in critically ill patient populations. Hypomagnesemia has been identified as the most common electrolyte abnormality in canine and feline critically ill patients. Magnesium depletion and experience with supplementation appear to have most significance in diabetic ketoacidotic patients with the development of associated refractory hypokalemia. (N. Dhupa, BVM, MRCVS, unpublished observations, 1997). Although cardiac arrythmias are associated with hypomagnesemia in human patients, documentation of this association in veterinary patients is lacking. Because hypomagnesemia has been associated with other electrolyte abnormalities in human and veterinary populations, the detection of hypokalemia (particularly if refractory to therapy), hyponatremia, hypophosphatemia, or hypocalcemia should indicate the possibility of coexisting hypomagnesemia.

Hypercalcemia and hypermagnesemia

Hypercalcemia and hypermagnesemia occur infrequently in small animal patients. Specific clinical signs usually do not accompany these electrolyte disorders, and their presence is often recognized only after reviewing serum chemistry profile results. The etiologies, clinical signs, and therapies for each electrolyte disorder are discussed in this article. Treatment of these disorders is aimed at correcting the underlying disease process and enhancing the removal of calcium or magnesium from the body. In severe cases, rescue therapies and resuscitative measures are required to stabilize the patient.