1
|
Tednes P, Marquardt S, Kuhrau S, Heagler K, Rech M. Keeping It "Current": A Review of Treatment Options for the Management of Supraventricular Tachycardia. Ann Pharmacother 2024; 58:715-727. [PMID: 37743672 DOI: 10.1177/10600280231199136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
OBJECTIVE To review treatment options and updates that exist for the management of paroxysmal supraventricular tachycardia (PSVT). DATA SOURCES A literature search of PubMed was performed including articles from 1974 to June 2023 using the terms: arrhythmias, adenosine, verapamil, diltiazem, esmolol, propranolol, metoprolol, beta-blockers, amiodarone, PSVT, synchronized cardioversion, methylxanthines, dipyridamole, pediatrics, heart transplant, and pregnancy. Primary literature and guidelines were reviewed. STUDY SELECTION AND DATA EXTRACTION Studies were considered if they were available in English and conducted in humans. DATA SYNTHESIS PSVT is a subset of supraventricular tachycardia (SVT) that presents as a rapid, regular tachycardia with an abrupt onset and termination. Due to frequent emergency department (ED) visits annually with symptoms of PSVT, appropriate and efficient management of these patients is vital. This review provides an overview of the pathophysiology of PSVT, while also describing the literature behind nonpharmacologic and pharmacologic management of PSVT. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review describes new literature regarding the improved success of the modified Valsalva maneuver as a nonpharmacologic therapy in PSVT. In addition, it describes a new technique in administration of adenosine that has improved outcomes, defines dose adjustments needed for drug interactions with adenosine, compares the utilization of nondihydropyridine calcium channel blockers with adenosine, and provides management recommendations for patients in special populations. CONCLUSIONS With high annual rates of ED visits for SVT, providers should be aware of the data behind management and modifications of therapy based on patient-specific factors (ie, patient preference, pharmacokinetics/pharmacodynamics, drug interactions, and special populations).
Collapse
Affiliation(s)
- Patrick Tednes
- Department of Pharmacy, Ascension Resurrection Medical Center, Chicago, IL, USA
| | - Samantha Marquardt
- Department of Pharmacy, Ascension Resurrection Medical Center, Chicago, IL, USA
| | - Shannon Kuhrau
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL, USA
| | - Kristin Heagler
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL, USA
| | - Megan Rech
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Department of Emergency Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| |
Collapse
|
2
|
Peng G, Zei PC. Diagnosis and Management of Paroxysmal Supraventricular Tachycardia. JAMA 2024; 331:601-610. [PMID: 38497695 DOI: 10.1001/jama.2024.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Importance Paroxysmal supraventricular tachycardia (PSVT), defined as tachyarrhythmias that originate from or conduct through the atria or atrioventricular node with abrupt onset, affects 168 to 332 per 100 000 individuals. Untreated PSVT is associated with adverse outcomes including high symptom burden and tachycardia-mediated cardiomyopathy. Observations Approximately 50% of patients with PSVT are aged 45 to 64 years and 67.5% are female. Most common symptoms include palpitations (86%), chest discomfort (47%), and dyspnea (38%). Patients may rarely develop tachycardia-mediated cardiomyopathy (1%) due to PSVT. Diagnosis is made on electrocardiogram during an arrhythmic event or using ambulatory monitoring. First-line acute therapy for hemodynamically stable patients includes vagal maneuvers such as the modified Valsalva maneuver (43% effective) and intravenous adenosine (91% effective). Emergent cardioversion is recommended for patients who are hemodynamically unstable. Catheter ablation is safe, highly effective, and recommended as first-line therapy to prevent recurrence of PSVT. Meta-analysis of observational studies shows single catheter ablation procedure success rates of 94.3% to 98.5%. Evidence is limited for the effectiveness of long-term pharmacotherapy to prevent PSVT. Nonetheless, guidelines recommend therapies including calcium channel blockers, β-blockers, and antiarrhythmic agents as management options. Conclusion and Relevance Paroxysmal SVT affects both adult and pediatric populations and is generally a benign condition. Catheter ablation is the most effective therapy to prevent recurrent PSVT. Pharmacotherapy is an important component of acute and long-term management of PSVT.
Collapse
Affiliation(s)
- Gary Peng
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paul C Zei
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
3
|
Ray L, Geier C, DeWitt KM. Pathophysiology and treatment of adults with arrhythmias in the emergency department, part 1: Atrial arrhythmias. Am J Health Syst Pharm 2023; 80:1039-1055. [PMID: 37227130 DOI: 10.1093/ajhp/zxad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Indexed: 05/26/2023] Open
Abstract
PURPOSE This article, the first in a 2-part review, aims to reinforce current literature on the pathophysiology of cardiac arrhythmias and various evidence-based treatment approaches and clinical considerations in the acute care setting. Part 1 of this series focuses on atrial arrhythmias. SUMMARY Arrhythmias are prevalent throughout the world and a common presenting condition in the emergency department (ED) setting. Atrial fibrillation (AF) is the most common arrhythmia worldwide and expected to increase in prevalence. Treatment approaches have evolved over time with advances in catheter-directed ablation. Based on historic trials, heart rate control has been the long-standing accepted outpatient treatment modality for AF, but the use of antiarrhythmics is often still indicated for AF in the acute setting, and ED pharmacists should be prepared and poised to help in AF management. Other atrial arrhythmias include atrial flutter (AFL), atrioventricular nodal reentry tachycardia (AVNRT), and atrioventricular reentrant tachycardia (AVRT), which warrant distinction due to their unique pathophysiology and because each requires a different approach to utilization of antiarrhythmics. Atrial arrhythmias are typically associated with greater hemodynamic stability than ventricular arrhythmias but still require nuanced management according to patient subset and risk factors. Since antiarrhythmics can also be proarrhythmic, they may destabilize the patient due to adverse effects, many of which are the focus of black-box label warnings that can be overreaching and limit treatment options. Electrical cardioversion for atrial arrhythmias is generally successful and, depending on the setting and/or hemodynamics, often indicated. CONCLUSION Atrial arrhythmias arise from a variety of mechanisms, and appropriate treatment depends on various factors. A firm understanding of physiological and pharmacological concepts serves as a foundation for exploring evidence supporting agents, indications, and adverse effects in order to provide appropriate care for patients.
Collapse
Affiliation(s)
- Lance Ray
- Denver Health and Hospital Authority, Denver, CO
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | - Curtis Geier
- San Francisco General Hospital, San Francisco, CA, USA
| | - Kyle M DeWitt
- University of Vermont Medical Center, Burlington, VT, USA
| |
Collapse
|
4
|
Iwańczyk S, Woźniak P, Smukowska-Gorynia A, Araszkiewicz A, Nowak A, Jankowski M, Konwerska A, Urbanowicz T, Lesiak M. Microcirculatory Disease in Patients after Heart Transplantation. J Clin Med 2023; 12:jcm12113838. [PMID: 37298033 DOI: 10.3390/jcm12113838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
Although the treatment and prognosis of patients after heart transplantation have significantly improved, late graft dysfunction remains a critical problem. Two main subtypes of late graft dysfunction are currently described: acute allograft rejection and cardiac allograft vasculopathy, and microvascular dysfunction appears to be the first stage of both. Studies revealed that coronary microcirculation dysfunction, assessed by invasive methods in the early post-transplant period, correlates with a higher risk of late graft dysfunction and death during long-term follow-up. The index of microcirculatory resistance, measured early after heart transplantation, might identify the patients at higher risk of acute cellular rejection and major adverse cardiovascular events. It may also allow optimization and enhancement of post-transplantation management. Moreover, cardiac allograft vasculopathy is an independent prognostic factor for transplant rejection and survival rate. The studies showed that the index of microcirculatory resistance correlates with anatomic changes and reflects the deteriorating physiology of the epicardial arteries. In conclusion, invasive assessment of the coronary microcirculation, including the measurement of the microcirculatory resistance index, is a promising approach to predict graft dysfunction, especially the acute allograft rejection subtype, during the first year after heart transplantation. However, further advanced studies are needed to fully grasp the importance of microcirculatory dysfunction in patients after heart transplantation.
Collapse
Affiliation(s)
- Sylwia Iwańczyk
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Patrycja Woźniak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Anna Smukowska-Gorynia
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | | | - Alicja Nowak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Maurycy Jankowski
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 60-701 Poznań, Poland
- Department of Histology and Embryology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Aneta Konwerska
- Department of Histology and Embryology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Tomasz Urbanowicz
- Cardiac Surgery and Transplantology Department, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| |
Collapse
|
5
|
Treatment of Arrhythmias During Pregnancy. Clin Obstet Gynecol 2023; 66:163-175. [PMID: 36162092 DOI: 10.1097/grf.0000000000000747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Cardiac disease is the most common cause of maternal mortality in developed nations. Cardiac arrhythmias are frequent among patients with structural heart disease and may require immediate treatment to prevent hemodynamic instability leading to acute maternal and fetal decompensation. Antiarrhythmic therapy during pregnancy should follow the same principles recommended for nonpregnant individuals. Although multidisciplinary management is recommended, obstetricians, and maternal-fetal medicine specialists may sometimes need to emergently recognize and treat rhythm anomalies before support services become available.
Collapse
|
6
|
Zhou W, Sin J, Yan AT, Wang H, Lu J, Li Y, Kim P, Patel AR, Ng MY. Qualitative and Quantitative Stress Perfusion Cardiac Magnetic Resonance in Clinical Practice: A Comprehensive Review. Diagnostics (Basel) 2023; 13:diagnostics13030524. [PMID: 36766629 PMCID: PMC9914769 DOI: 10.3390/diagnostics13030524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/11/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023] Open
Abstract
Stress cardiovascular magnetic resonance (CMR) imaging is a well-validated non-invasive stress test to diagnose significant coronary artery disease (CAD), with higher diagnostic accuracy than other common functional imaging modalities. One-stop assessment of myocardial ischemia, cardiac function, and myocardial viability qualitatively and quantitatively has been proven to be a cost-effective method in clinical practice for CAD evaluation. Beyond diagnosis, stress CMR also provides prognostic information and guides coronary revascularisation. In addition to CAD, there is a large body of literature demonstrating CMR's diagnostic performance and prognostic value in other common cardiovascular diseases (CVDs), especially coronary microvascular dysfunction (CMD). This review focuses on the clinical applications of stress CMR, including stress CMR scanning methods, practical interpretation of stress CMR images, and clinical utility of stress CMR in a setting of CVDs with possible myocardial ischemia.
Collapse
Affiliation(s)
- Wenli Zhou
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Jason Sin
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong SAR, China
| | - Andrew T. Yan
- St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada
| | | | - Jing Lu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Paul Kim
- Department of Medicine, University of California San Diego, San Diego, CA 92093, USA
| | - Amit R. Patel
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA 22903, USA
| | - Ming-Yen Ng
- Department of Medical Imaging, HKU-Shenzhen Hospital, Shenzhen 518009, China
- Department of Diagnostic Radiology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
- Correspondence:
| |
Collapse
|
7
|
Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 89] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
8
|
Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
9
|
Jiang Y, Lin J, Zheng H, Zhu P. The Role of Purinergic Signaling in Heart Transplantation. Front Immunol 2022; 13:826943. [PMID: 35529844 PMCID: PMC9069525 DOI: 10.3389/fimmu.2022.826943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
Heart transplantation remains the optimal treatment option for patients with end-stage heart disease. Growing evidence demonstrates that purinergic signals mediated by purine nucleotides and nucleosides play vital roles in heart transplantation, especially in the era of ischemia-reperfusion injury (IRI) and allograft rejection. Purinergic signaling consists of extracellular nucleotides and nucleosides, ecto-enzymes, and cell surface receptors; it participates in the regulation of many physiological and pathological processes. During transplantation, excess adenosine triphosphate (ATP) levels are released from damaged cells, and driver detrimental inflammatory responses largely via purinergic P2 receptors. Ecto-nucleosidases sequentially dephosphorylate extracellular ATP to ADP, AMP, and finally adenosine. Adenosine exerts a cardioprotective effect by its anti-inflammatory, antiplatelet, and vasodilation properties. This review focused on the role of purinergic signaling in IRI and rejection after heart transplantation, as well as the clinical applications and prospects of purinergic signaling.
Collapse
|
10
|
Opatřil L, Panovsky R, Mojica-Pisciotti M, Máchal J, Krejčí J, Holeček T, Masárová L, Feitová V, Godava J, Kincl V, Kepák T, Závodná G, Špinarová L. Stress pulmonary circulation parameters assessed by a cardiovascular magnetic resonance in patients after a heart transplant. Sci Rep 2022; 12:6130. [PMID: 35414701 PMCID: PMC9005501 DOI: 10.1038/s41598-022-09739-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 03/21/2022] [Indexed: 11/09/2022] Open
Abstract
Rest pulmonary circulation parameters such as pulmonary transit time (PTT), heart rate corrected PTT (PTTc) and pulmonary transit beats (PTB) can be evaluated using several methods, including the first-pass perfusion from cardiovascular magnetic resonance. As previously published, up to 58% of patients after HTx have diastolic dysfunction detectable only in stress conditions. By using adenosine stress perfusion images, stress analogues of the mentioned parameters can be assessed. By dividing stress to rest biomarkers, potential new ratio parameters (PTT ratio and PTTc ratio) can be obtained. The objectives were to (1) provide more evidence about stress pulmonary circulation biomarkers, (2) present stress to rest ratio parameters, and (3) assess these biomarkers in patients with presumed diastolic dysfunction after heart transplant (HTx) and in childhood cancer survivors (CCS) without any signs of diastolic dysfunction. In this retrospective study, 48 patients after HTx, divided into subgroups based on echocardiographic signs of diastolic dysfunction (41 without, 7 with) and 39 CCS were enrolled. PTT was defined as the difference between the onset time of the signal intensity increase in the left and the right ventricle. PTT in rest conditions were without significant differences when comparing the CCS and HTx subgroup without diastolic dysfunction (4.96 ± 0.93 s vs. 5.51 ± 1.14 s, p = 0.063) or with diastolic dysfunction (4.96 ± 0.93 s vs. 6.04 ± 1.13 s, p = 0.13). However, in stress conditions, both PTT and PTTc were significantly lower in the CCS group than in the HTx subgroups, (PTT: 3.76 ± 0.78 s vs. 4.82 ± 1.03 s, p < 0.001; 5.52 ± 1.56 s, p = 0.002). PTT ratio and PTTc ratio were below 1 in all groups. In conclusion, stress pulmonary circulation parameters obtained from CMR showed prolonged PTT and PTTc in HTx groups compared to CCS, which corresponds with the presumption of underlying diastolic dysfunction. The ratio parameters were less than 1.
Collapse
Affiliation(s)
- Lukáš Opatřil
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic.,International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Panovsky
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic. .,International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic. .,Faculty of Medicine, Masaryk University, Brno, Czech Republic. .,First Department of Internal Medicine and Cardioangiology, International Clinical Research Centre, Faculty of Medicine, Masaryk University, St. Anne's University Hospital, Brno, Czech Republic.
| | - Mary Mojica-Pisciotti
- International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic
| | - Jan Máchal
- International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic.,Department of Pathophysiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Krejčí
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomáš Holeček
- International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic.,Department of Medical Imaging, St. Anne's University Hospital, Brno, Czech Republic
| | - Lucia Masárová
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic.,International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Věra Feitová
- International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic.,Department of Medical Imaging, St. Anne's University Hospital, Brno, Czech Republic
| | - Július Godava
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic
| | - Vladimír Kincl
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic.,International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomáš Kepák
- International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic.,Department of Paediatric Oncology, University Hospital Brno, Brno, Czech Republic
| | | | - Lenka Špinarová
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital, Pekarska 53, 656 91, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| |
Collapse
|
11
|
Gupta A, Sehgal S, Bansal N. Emergency Department Management of Pediatric Heart Transplant Recipients: Unique Immunologic and Hemodynamic Challenges. J Emerg Med 2022; 62:154-162. [PMID: 35031170 DOI: 10.1016/j.jemermed.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 09/19/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Since the first heart transplant in 1967, there has been significant progress in this field of cardiac transplantation. Approximately 600 pediatric heart transplants are performed every year worldwide. With the increasing number of pediatric heart transplant patients, and given the few tertiary care pediatric transplant centers, adult and pediatric emergency department (ED) providers are increasingly engaged in the care of pediatric heart transplant recipients in the ED. OBJECTIVE The aim of this article is to review common ED scenarios pertinent to the pediatric heart transplant patients. DISCUSSION There are complications unique to this population, such as rejection, opportunistic infections, and medication side effects, that require special considerations, and it is helpful for the emergency medicine (EM) provider to have knowledge about them. CONCLUSIONS The unique immunological challenges in these patients, including rejection and medication side effects and opportunistic infections, make this population fragile, and the knowledge of these challenges is helpful for EM providers.
Collapse
Affiliation(s)
- Aditi Gupta
- Department of Pediatrics, Lincoln Medical and Mental Health Center, Bronx, New York
| | - Swati Sehgal
- Division of Pediatric Cardiology, Children's Hospital of Michigan, Detroit, Michigan
| | - Neha Bansal
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York.
| |
Collapse
|
12
|
Duran SR, Huffaker T, Dixon B, Gooty V, Abou Zahr R, Arar Y, Greer JS, Butts RJ, Hussain MT. Feasibility and safety of quantitative adenosine stress perfusion cardiac magnetic resonance imaging in pediatric heart transplant patients with and without coronary allograft vasculopathy. Pediatr Radiol 2021; 51:1311-1321. [PMID: 33791838 DOI: 10.1007/s00247-021-04977-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 11/11/2020] [Accepted: 01/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pediatric heart transplant patients require cardiac catheterization to monitor for coronary allograft vasculopathy. Cardiac catheterization has no safe and consistent method for measuring microvascular disease. Stress perfusion cardiac magnetic resonance imaging (MRI) assessing microvascular disease has been performed in adults. OBJECTIVE To investigate the feasibility and safety of performing cardiac MRI with quantitative adenosine stress perfusion testing in pediatric heart transplant patients with and without coronary allograft vasculopathy. MATERIALS AND METHODS All pediatric heart transplant patients with coronary vasculopathy at our institution were asked to participate. Age- and gender-matched pediatric heart transplant patients without vasculopathy were recruited for comparison. Patients underwent cardiac MRI with adenosine stress perfusion testing. RESULTS Sixteen pediatric heart transplant patients, ages 6-22 years, underwent testing. Nine patients had vasculopathy by angiography. No heart block or other complications occurred during the study. The myocardial perfusion reserve for patients with vasculopathy showed no significant difference with comparison patients (median: 1.43 vs. 1.48; P=0.49). Values for both groups were lower than expected values based on previous adult studies. The patients were also analyzed for time after transplant and the number of rejection episodes. Patients within 6 years of transplantation had a nonsignificant trend toward a higher myocardial perfusion reserve (median: 1.57) versus patients with older transplants (median: 1.47; P=0.46). Intra- and interobserver reproducibility were 97% and 92%, respectively. CONCLUSION Myocardial perfusion reserve is a safe and feasible method for estimating myocardial perfusion in pediatric heart transplant patients. There is no reliable way to monitor microvascular disease in pediatric patients. This method shows potential and deserves investigation in a larger cohort.
Collapse
Affiliation(s)
- Silvestre R Duran
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA. .,Division of Pediatric Cardiology, Children's Medical Center Dallas, Dallas, TX, USA. .,Division of Pediatric Cardiology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA.
| | - Tyler Huffaker
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Bryant Dixon
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Vasu Gooty
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.,Division of Pediatric Cardiology, Children's Medical Center Dallas, Dallas, TX, USA
| | - Riad Abou Zahr
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.,Division of Pediatric Cardiology, Children's Medical Center Dallas, Dallas, TX, USA
| | - Yousef Arar
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.,Division of Pediatric Cardiology, Children's Medical Center Dallas, Dallas, TX, USA
| | - Joshua S Greer
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Ryan J Butts
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.,Division of Pediatric Cardiology, Children's Medical Center Dallas, Dallas, TX, USA
| | - Mohammad T Hussain
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.,Division of Pediatric Cardiology, Children's Medical Center Dallas, Dallas, TX, USA
| |
Collapse
|
13
|
Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2021; 41:655-720. [PMID: 31504425 DOI: 10.1093/eurheartj/ehz467] [Citation(s) in RCA: 497] [Impact Index Per Article: 165.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
|
14
|
Joglar JA, Wan EY, Chung MK, Gutierrez A, Slaughter MS, Bateson BP, Loguidice M, Drazner M, Kistler PM, Saour B, Poole JE, Murtaza G, Turagam MK, Vader J, Lakkireddy D, Birati EY, Dhingra R, Gopinathannair R. Management of Arrhythmias After Heart Transplant: Current State and Considerations for Future Research. Circ Arrhythm Electrophysiol 2021; 14:e007954. [PMID: 33685207 DOI: 10.1161/circep.120.007954] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Orthotropic heart transplantation remains the most effective therapy for patients with end-stage heart failure, with a median survival of ≈13 years. Yet, a number of complications are observed after orthotropic heart transplantation, including atrial and ventricular arrhythmias. Several factors contribute to arrhythmias, such as autonomic denervation, effect of the surgical technique, acute and chronic rejection, and transplant vasculopathy among others. To minimize risk of future arrhythmias, the bicaval technique and minimizing ischemic time are current surgical standards. Sinus node dysfunction is the most common indication for early (within 30 days) pacemaker implantation, whereas atrioventricular block incidence increases as time from transplant increases. Atrial fibrillation can occur in the first few weeks following transplantation but is uncommon in the long term unless secondary to a precipitant such as acute rejection. The most common atrial arrhythmias are atrial flutters, which are mainly typical, but atypical circuits can be observed such as those that involve the remnant donor atrium in regions immediately adjacent to the atrioatrial anastomosis suture line. Choosing the appropriate pharmacological therapy requires careful consideration due to the potential interaction with immunosuppressive agents. Despite historical concerns, adenosine is effective and safe at reduced doses if administered under cardiac monitoring. Catheter ablation has emerged as an effective treatment strategy for symptomatic supraventricular tachycardias, including ablation of atypical flutter circuits. Cardiac allograft vasculopathy is an important risk factor for sudden cardiac death, yet the role of prophylactic implantable cardioverter-defibrillator implant for sudden death prevention is unclear. Current indications for implantable cardioverter-defibrillator implantation are as in the nontransplant population. A number of questions for future research are posed.
Collapse
Affiliation(s)
- Jose A Joglar
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (J.A.J., M.L., M.D.)
| | - Elaine Y Wan
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY (E.Y.W.)
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH (M.K.C.).,Department of Cardiovascular Medicine, Icahn School of Medicine at Mount Sinai, New York, NY (M.K.T.)
| | | | - Mark S Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, KY (M.S.S., B.P.B.)
| | - Brian P Bateson
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, KY (M.S.S., B.P.B.)
| | - Michael Loguidice
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (J.A.J., M.L., M.D.)
| | - Mark Drazner
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (J.A.J., M.L., M.D.)
| | - Peter M Kistler
- Heart Centre, The Alfred Hospital, Melbourne, Australia (P.M.K.)
| | - Basil Saour
- Department of Internal Medicine, University of Washington, Seattle (B.S., J.E.P.)
| | - Jeanne E Poole
- Department of Internal Medicine, University of Washington, Seattle (B.S., J.E.P.)
| | - Ghulam Murtaza
- Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS (G.M., D.L., R.G.)
| | | | - Justin Vader
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (J.V.)
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS (G.M., D.L., R.G.)
| | - Edo Y Birati
- Advanced Heart Failure/Transplantation Program, Division of Cardiovascular Medicine, Department of Internal Medicine, Perelman School of Medicine, Philadelphia, PA (E.Y.B.)
| | - Ravi Dhingra
- Advanced Heart Disease and Transplant, Division of Cardiology, University of Wisconsin, Madison (R.D.)
| | - Rakesh Gopinathannair
- Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS (G.M., D.L., R.G.)
| |
Collapse
|
15
|
Jiménez Jaso J, Ezponda A, Muñiz Sáenz-Diez J, Caballeros M, Rábago G, Bastarrika G. Cardiac magnetic resonance imaging myocardial perfusion reserve index in heart transplant patients. RADIOLOGIA 2020. [DOI: 10.1016/j.rxeng.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
16
|
Xing W, Li T, Wang Y, Qiang Y, Ai C, Tang H. MiR-33a-5p targets NOMO1 to modulate human cardiomyocyte progenitor cells proliferation and differentiation and apoptosis. J Recept Signal Transduct Res 2020; 41:476-487. [PMID: 33054489 DOI: 10.1080/10799893.2020.1825492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE MicroRNA (miRNA) is known to be involved in the pathological process of congenital heart disease (CHD), and nodal modulator1 (NOMO1) is a critical determinant of heart formation. The present study aims to discover the effect of miR-33a-5p and NOMO1 on CHD. METHODS Quantitative real-time polymerase chain reaction (qRT-PCR) was used to detect expressions of miR-33a-5p mimic or inhibitor and overexpressed NOMO1 plasmid orNOMO1 knockdown. Human cardiomyocyte progenitor cells (hCMPCs) proliferation was measured by cell counting kit-8 (CCK-8) at 24, 48 and 72 h. Flow cytometry was applied to investigate hCMPCs cell cycle progression and apoptosis. Expressions of cell apoptotic proteins Bax, Cleaved(C) caspase-3 and Bcl-2, and expressions of cardiomyocyte differentiation markers GATA4, troponin T (cTnT) and myocyte enhancer factor2C (MEF2C) in hCMPCs were identified by qRT-PCR and western blot. Target genes and potential binding sites of NOMO1 and miR-33a-5p were predicted with Targetscan 7.2, and was confirmed through dual-luciferase reporter assay. RESULTS Up-regulation of miR-33a-5p inhibited hCMPCs proliferation, cell cycle G0/S transition but promoted hCMPCs apoptosis, which was partially mitigated by overexpressed NOMO1. NOMO1 was the target gene of miR-33a-5p. Expressions of Bax and C caspase-3 were enhanced but expressions of Bcl-2, GATA4, cTnT and MEF2C were reduced by up-regulation of miR-33a-5p, which was partially mitigated by overexpressed NOMO1. CONCLUSION Up-regulation of miR-33a-5p inhibited hCMPCs proliferation, cell cycle G0/S transition and differentiation into cardiomyocytes but promoted apoptosis via targeting NOMO1.
Collapse
Affiliation(s)
- Wang Xing
- Cardiovascular Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou City, China
| | - Tiangang Li
- Department of Ultrasonography, Gansu Provincial Maternity and Child-care Hospital, Lanzhou City, China
| | - Yixuan Wang
- Department of Ultrasonography, Gansu Provincial Maternity and Child-care Hospital, Lanzhou City, China
| | - Yi Qiang
- Cardiovascular Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou City, China
| | - Chencheng Ai
- Cardiovascular Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou City, China
| | - Hanbo Tang
- Cardiovascular Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou City, China
| |
Collapse
|
17
|
Jiménez-Jaso JM, Ezponda A, Sáenz-Diez JM, Caballeros M, Rábago G, Bastarrika G. Cardiac magnetic resonance imaging myocardial perfusion reserve index in heart transplant patients. RADIOLOGIA 2020; 62:493-501. [PMID: 32493651 DOI: 10.1016/j.rx.2020.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/01/2020] [Accepted: 04/14/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare the myocardial perfusion reserve index (MPRI) measured during stress cardiac magnetic resonance imaging (MRI) with regadenoson in patients with heart transplants versus in patients without heart transplants. MATERIAL AND METHODS We retrospectively compared 20 consecutive asymptomatic heart transplant patients without suspicion of microvascular disease who underwent stress cardiac MRI with regadenoson and coronary computed tomography angiography (CTA) to rule out cardiac allograft vasculopathy versus 16 patients without transplants who underwent clinically indicated stress cardiac MRI who were negative for ischemia and had no signs of structural heart disease. We estimated MPRI semiquantitatively after calculating the up-slope of the first-pass enhancement curve and dividing the value obtained during stress by the value obtained at rest. We compared MPRI in the two groups. Patients with positive findings for ischemia on stress cardiac MRI or significant coronary stenosis on coronary CTA were referred for conventional coronary angiography. RESULTS More than half the patients remained asymptomatic during the stress test. Stress cardiac MRI was positive for ischemia in two heart transplant patients; these findings were confirmed at coronary CTA and at conventional coronary angiography. Patients with transplants had lower end-diastolic volume index (59.3±15.2 ml/m2 vs. 71.4±15.9 ml/m2 in those without transplants, p=0.03), lower MPRI (1.35±0.19 vs. 1.6±0.28 in those without transplants, p=0.003), and a less pronounced hemodynamic response to regadenoson (mean increase in heart rate 13.1±5.4 bpm vs. 28.5±8.9 bpm in those without transplants, p <0.001). CONCLUSION Stress cardiac MRI with regadenoson is safe. In the absence of epicardial coronary artery disease, patients with heart transplants have lower MPRI than patients without transplants, suggesting microvascular disease. The hemodynamic response to regadenoson is less pronounced in patients with heart transplants than in patients without heart transplants.
Collapse
Affiliation(s)
- J M Jiménez-Jaso
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - A Ezponda
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - J Muñiz Sáenz-Diez
- Departamento de Cardiología, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - M Caballeros
- Servicio de Radiología, Clínica Universidad de Navarra, Madrid, España
| | - G Rábago
- Departamento de Cirugía Cardíaca, Clínica Universidad de Navarra, Pamplona, España
| | - G Bastarrika
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España.
| |
Collapse
|
18
|
Satzer MB, Flyer JN, Zuckerman WA, Liberman L, Richmond ME, Anderson BR, Addonizio LJ, Silver ES. Impact of dipyridamole on adenosine dosing in pediatric and young adult patients after heart transplantation. Pediatr Transplant 2020; 24:e13689. [PMID: 32157785 PMCID: PMC9610548 DOI: 10.1111/petr.13689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 02/08/2020] [Accepted: 02/12/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Relative contraindications to adenosine use have included heart transplant and dipyridamole. We previously demonstrated the safety and efficacy of adenosine-induced atrioventricular (AV) block in healthy young heart transplant recipients while suspending dipyridamole therapy (dual antiplatelet agent). This prospective follow-up study evaluated the safety and efficacy of adenosine use in the same cohort of heart transplant recipients while on dipyridamole. METHODS Adenosine was incrementally dosed until AV block occurred (maximum 200 mcg/kg up to 12 mg). The primary outcome was clinically significant asystole (≥12 seconds). Secondary outcomes included maximal adenosine dose, AV block duration, dysrhythmias, and clinical symptoms. Outcomes were compared to the parent study. RESULTS Thirty of 39 eligible patients (5-24 years) were tested. No patient (0%, CI 0%-8%) experienced clinically significant asystole. AV block occurred in 29/30 patients (97%, CI 86%-100%). The median dose causing AV block was 50mcg/kg (vs 100 mcg/kg off dipyridamole; P = .011). Seventeen patients (57%, CI 39%-72%) required less adenosine to achieve AV block on dipyridamole; six (20%) required more. AV block occurred at doses ≥25 mcg/kg in all patients. In pairwise comparison to prior testing off dipyridamole, no significant change occurred in AV block duration, frequency of cardiac ectopy, or incidence of reported symptoms. No atrial fibrillation/flutter occurred. CONCLUSIONS AV block often occurs at twofold lower adenosine doses in healthy young heart transplant recipients taking oral dipyridamole, compared with previous testing of this cohort off dipyridamole. Results suggest that initial dosing of 25 mcg/kg (maximum 0.8 mg) with stepwise escalation poses low risk of prolonged asystole on dipyridamole.
Collapse
Affiliation(s)
- Michael B. Satzer
- Division of Pediatric Cardiology Columbia University Irving Medical Center New York NY USA
| | - Jonathan N. Flyer
- Division of Pediatric Cardiology Columbia University Irving Medical Center New York NY USA
- Department of Pediatrics Division of Pediatric Cardiology The Robert Larner, M.D. College of Medicine at The University of Vermont Burlington VT USA
| | - Warren A. Zuckerman
- Division of Pediatric Cardiology Columbia University Irving Medical Center New York NY USA
| | - Leonardo Liberman
- Division of Pediatric Cardiology Columbia University Irving Medical Center New York NY USA
| | - Marc E. Richmond
- Division of Pediatric Cardiology Columbia University Irving Medical Center New York NY USA
| | - Brett R. Anderson
- Division of Pediatric Cardiology Columbia University Irving Medical Center New York NY USA
| | - Linda J. Addonizio
- Division of Pediatric Cardiology Columbia University Irving Medical Center New York NY USA
| | - Eric S. Silver
- Division of Pediatric Cardiology Columbia University Irving Medical Center New York NY USA
| |
Collapse
|
19
|
Yeudall S, Leitinger N, Laubach VE. Extracellular nucleotide signaling in solid organ transplantation. Am J Transplant 2020; 20:633-640. [PMID: 31605463 PMCID: PMC7042041 DOI: 10.1111/ajt.15651] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/12/2019] [Accepted: 09/25/2019] [Indexed: 01/25/2023]
Abstract
The role of extracellular purine nucleotides, including adenosine triphosphate (ATP) and adenosine, as modulators of posttransplantation outcome and ischemia-reperfusion injury is becoming increasingly evident. Upon pathological release of ATP, binding and activation of P2 purinergic surface receptors promote tissue injury and inflammation, while the expression and activation of P1 receptors for adenosine have been shown to attenuate inflammation and limit ischemia-induced damage, which are central to the viability and long-term success of allografts. Here we review the current state of the transplant field with respect to the role of extracellular nucleotide signaling, with a focus on the sources and functions of extracellular ATP. The connection between ischemia reperfusion, purinergic signaling, and graft preservation, as well as the role of ATP and adenosine as driving factors in the promotion and suppression of posttransplant inflammation and allograft rejection, are discussed. We also examine novel therapeutic approaches that take advantage of the ischemia-reperfusion-responsive and immunomodulatory roles for purinergic signaling with the goal of enhancing graft viability, attenuating posttransplant inflammation, and minimizing complications including rejection, graft failure, and associated comorbidities.
Collapse
Affiliation(s)
- Scott Yeudall
- Department of Pharmacology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Norbert Leitinger
- Department of Pharmacology, University of Virginia School of Medicine, Charlottesville, Virginia,Robert M. Berne Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Victor E. Laubach
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| |
Collapse
|
20
|
Matthews GDK, Grace AA. Unmasking Adenosine: The Purinergic Signalling Molecule Critical to Arrhythmia Pathophysiology and Management. Arrhythm Electrophysiol Rev 2020; 8:240-248. [PMID: 32685154 PMCID: PMC7358948 DOI: 10.15420/aer.2019.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Adenosine was identified in 1929 and immediately recognised as having a potential role in therapy for arrhythmia because of its negative chronotropic and dromotropic effects. Adenosine entered mainstream use in the 1980s as a highly effective agent for the termination of supraventricular tachycardia (SVT) involving the atrioventricular node, as well as for its ability to unmask the underlying rhythm in other SVTs. Adenosine has subsequently been found to have applications in interventional electrophysiology. While considered a safe agent because of its short half-life, adenosine may provoke arrhythmias in the form of AF, bradyarrhythmia and ventricular tachyarrhythmia. Adenosine is also associated with bronchospasm, although this may reflect irritant-induced dyspnoea rather than true obstruction. Adenosine is linked to numerous pathologies relevant to arrhythmia predisposition, including heart failure, obesity, ischaemia and the ageing process itself. This article examines 90 years of experience with adenosine in the light of new European Society of Cardiology guidelines for the management of SVT.
Collapse
Affiliation(s)
- Gareth DK Matthews
- Cambridge University NHS Foundation Trust, Cambridge, UK; Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Andrew A Grace
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK; Department of Biochemistry, University of Cambridge, Cambridge, UK
| |
Collapse
|
21
|
Waits G, Kim J. A Young Woman with Someone Else's Heart. Methodist Debakey Cardiovasc J 2020; 16:e8. [PMID: 32280426 PMCID: PMC7137629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023] Open
Affiliation(s)
- George Waits
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Ju Kim
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| |
Collapse
|
22
|
Reiss AB, Grossfeld D, Kasselman LJ, Renna HA, Vernice NA, Drewes W, Konig J, Carsons SE, DeLeon J. Adenosine and the Cardiovascular System. Am J Cardiovasc Drugs 2019; 19:449-464. [PMID: 30972618 PMCID: PMC6773474 DOI: 10.1007/s40256-019-00345-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Adenosine is an endogenous nucleoside with a short half-life that regulates many physiological functions involving the heart and cardiovascular system. Among the cardioprotective properties of adenosine are its ability to improve cholesterol homeostasis, impact platelet aggregation and inhibit the inflammatory response. Through modulation of forward and reverse cholesterol transport pathways, adenosine can improve cholesterol balance and thereby protect macrophages from lipid overload and foam cell transformation. The function of adenosine is controlled through four G-protein coupled receptors: A1, A2A, A2B and A3. Of these four, it is the A2A receptor that is in a large part responsible for the anti-inflammatory effects of adenosine as well as defense against excess cholesterol accumulation. A2A receptor agonists are the focus of efforts by the pharmaceutical industry to develop new cardiovascular therapies, and pharmacological actions of the atheroprotective and anti-inflammatory drug methotrexate are mediated via release of adenosine and activation of the A2A receptor. Also relevant are anti-platelet agents that decrease platelet activation and adhesion and reduce thrombotic occlusion of atherosclerotic arteries by antagonizing adenosine diphosphate-mediated effects on the P2Y12 receptor. The purpose of this review is to discuss the effects of adenosine on cell types found in the arterial wall that are involved in atherosclerosis, to describe use of adenosine and its receptor ligands to limit excess cholesterol accumulation and to explore clinically applied anti-platelet effects. Its impact on electrophysiology and use as a clinical treatment for myocardial preservation during infarct will also be covered. Results of cell culture studies, animal experiments and human clinical trials are presented. Finally, we highlight future directions of research in the application of adenosine as an approach to improving outcomes in persons with cardiovascular disease.
Collapse
|
23
|
Complications After Heart Transplantation in Adults: an Update. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40138-019-00180-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
24
|
Follansbee CW, Beerman LB, Wu L, Bertolet M, Arora G. Utility and safety of adenosine challenge for subtle ventricular pre-excitation in the pediatric population. J Cardiovasc Electrophysiol 2019; 30:1036-1041. [PMID: 30938913 DOI: 10.1111/jce.13935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 03/07/2019] [Accepted: 03/22/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Adenosine challenge (AC) can be used to evaluate possible Wolff-Parkinson-White (WPW) pattern on an electrocardiogram (ECG). Despite the use of this technique, there is a paucity of studies in the pediatric population evaluating the efficacy, safety, and outcomes of this testing modality. METHODS AND RESULTS All ACs performed from January 2009 to June 2017 were retrospectively reviewed. Patient demographics, adenosine dosing, results, adverse effects, and outcomes including results of electrophysiology studies (EPS) were reviewed. Analysis was conducted between AC positive and negative cohorts. ECG criteria of shortest PR interval, longest QRS duration, and the number of suspected pre-excited leads were evaluated for inter-rater reliability and correlation to positive AC. Fifty-six AC (n = 51) were performed (median age, 13.8; range, 0.3-20 years). Forty-one AC were pre-EPS and 15 post-EPS due to concern for recurrent WPW. Thirty-one (76%) pre-EPS AC were negative, 9 (22%) positive, and 1 (2%) equivocal. EPS was performed following seven positive AC revealing 5 (71%) left posterior and 2 (29%) right posteroseptal AP. The 15 post-EPS AC were all found to be negative. Mean effective adenosine dose was 0.2 ± 0.11 mg/kg. No adverse events were reported. Mean follow up duration after AC was 314 ± 482 days with no documented arrhythmias. CONCLUSION Adenosine challenge is an effective and safe testing modality for subtle WPW in the pediatric population. In our population, there were no adverse events or documented arrhythmias in patients following a negative study.
Collapse
Affiliation(s)
- Christopher W Follansbee
- Division of Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Lee B Beerman
- Division of Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Liwen Wu
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marnie Bertolet
- Department of Epidemiology and The Clinical and Translational Science Institute, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gaurav Arora
- Division of Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| |
Collapse
|
25
|
Jacobson KA, Tosh DK, Jain S, Gao ZG. Historical and Current Adenosine Receptor Agonists in Preclinical and Clinical Development. Front Cell Neurosci 2019; 13:124. [PMID: 30983976 PMCID: PMC6447611 DOI: 10.3389/fncel.2019.00124] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/13/2019] [Indexed: 12/22/2022] Open
Abstract
Adenosine receptors (ARs) function in the body’s response to conditions of pathology and stress associated with a functional imbalance, such as in the supply and demand of energy/oxygen/nutrients. Extracellular adenosine concentrations vary widely to raise or lower the basal activation of four subtypes of ARs. Endogenous adenosine can correct an energy imbalance during hypoxia and other stress, for example, by slowing the heart rate by A1AR activation or increasing the blood supply to heart muscle by the A2AAR. Moreover, exogenous AR agonists, antagonists, or allosteric modulators can be applied for therapeutic benefit, and medicinal chemists working toward that goal have reported thousands of such agents. Thus, numerous clinical trials have ensued, using promising agents to modulate adenosinergic signaling, most of which have not succeeded. Currently, short-acting, parenteral agonists, adenosine and Regadenoson, are the only AR agonists approved for human use. However, new concepts and compounds are currently being developed and applied toward preclinical and clinical evaluation, and initial results are encouraging. This review focuses on key compounds as AR agonists and positive allosteric modulators (PAMs) for disease treatment or diagnosis. AR agonists for treating inflammation, pain, cancer, non-alcoholic steatohepatitis, angina, sickle cell disease, ischemic conditions and diabetes have been under development. Multiple clinical trials with two A3AR agonists are ongoing.
Collapse
Affiliation(s)
- Kenneth A Jacobson
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Dilip K Tosh
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Shanu Jain
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Zhan-Guo Gao
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| |
Collapse
|
26
|
Ye Z, Su Q, Li L. Letter by Ye et al Regarding Article, "Prospective Study of Adenosine on Atrioventricular Nodal Conduction in Pediatric and Young Adult Patients After Heart Transplantation". Circulation 2019; 137:315-316. [PMID: 29335295 DOI: 10.1161/circulationaha.117.030307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ziliang Ye
- Department of Cardiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qiang Su
- Department of Cardiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lang Li
- Department of Cardiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| |
Collapse
|
27
|
Jacobson KA, Tosh DK, Jain S, Gao ZG. Historical and Current Adenosine Receptor Agonists in Preclinical and Clinical Development. Front Cell Neurosci 2019. [PMID: 30983976 DOI: 10.3389/fncel.2019.00124/bibtex] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Adenosine receptors (ARs) function in the body's response to conditions of pathology and stress associated with a functional imbalance, such as in the supply and demand of energy/oxygen/nutrients. Extracellular adenosine concentrations vary widely to raise or lower the basal activation of four subtypes of ARs. Endogenous adenosine can correct an energy imbalance during hypoxia and other stress, for example, by slowing the heart rate by A1AR activation or increasing the blood supply to heart muscle by the A2AAR. Moreover, exogenous AR agonists, antagonists, or allosteric modulators can be applied for therapeutic benefit, and medicinal chemists working toward that goal have reported thousands of such agents. Thus, numerous clinical trials have ensued, using promising agents to modulate adenosinergic signaling, most of which have not succeeded. Currently, short-acting, parenteral agonists, adenosine and Regadenoson, are the only AR agonists approved for human use. However, new concepts and compounds are currently being developed and applied toward preclinical and clinical evaluation, and initial results are encouraging. This review focuses on key compounds as AR agonists and positive allosteric modulators (PAMs) for disease treatment or diagnosis. AR agonists for treating inflammation, pain, cancer, non-alcoholic steatohepatitis, angina, sickle cell disease, ischemic conditions and diabetes have been under development. Multiple clinical trials with two A3AR agonists are ongoing.
Collapse
Affiliation(s)
- Kenneth A Jacobson
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Dilip K Tosh
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Shanu Jain
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Zhan-Guo Gao
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| |
Collapse
|
28
|
Joong A, Khan A. Emergency Department Evaluation of the Pediatric Heart Transplant Recipient. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
29
|
Jin-Shan H, Xue-Bin L. Letter by Jin-shan and Xue-bin Regarding Article, "Prospective Study of Adenosine on Atrioventricular Nodal Conduction in Pediatric and Young Adult Patients After Heart Transplantation". Circulation 2018; 137:314. [PMID: 29335294 DOI: 10.1161/circulationaha.117.030854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- He Jin-Shan
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Peking University People's Hospital, Beijing, China
| | - Li Xue-Bin
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Peking University People's Hospital, Beijing, China
| |
Collapse
|
30
|
Pediatric Tachyarrhythmias: Diagnosis and Management. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0148-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|