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Nazari MA, Dapas N, Pacak K, Zhuang Z, Rosenblum JS, Jha A, Towheed A, Haigney MC, Thomaides A, Srichai MB. Case report: Antidromic atrioventricular reentrant tachycardia and underlying Ebstein anomaly. Heliyon 2024; 10:e28895. [PMID: 38596017 PMCID: PMC11002677 DOI: 10.1016/j.heliyon.2024.e28895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 02/23/2024] [Accepted: 03/26/2024] [Indexed: 04/11/2024] Open
Abstract
Multiple accessory pathways (APs) can develop in patients with Ebstein anomaly. Rarely, these APs can participate in antidromic atrioventricular reentrant tachycardia (AVRT) which can be life-threatening and requires unique considerations for acute management and ultimate ablation. These considerations are discussed herein.
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Affiliation(s)
- Matthew A. Nazari
- MedStar Georgetown University Hospital, Washington DC, USA
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Natalie Dapas
- MedStar Georgetown University Hospital, Washington DC, USA
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Zhengping Zhuang
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jared S. Rosenblum
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Abhishek Jha
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Arooge Towheed
- MedStar Georgetown University Hospital, Washington DC, USA
- MedStar Washington Hospital Center, Washington DC, USA
| | - Mark C. Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Division of Cardiology, Department of Medicine, Walter Reed National Military Medical Center, USA and Herbert School of Medicine, Bethesda, MD, USA
| | - Athanasios Thomaides
- MedStar Georgetown University Hospital, Washington DC, USA
- MedStar Washington Hospital Center, Washington DC, USA
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2
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Solhjoo S, Haigney MC, Siddharthan T, Koch A, Punjabi NM. Sleep-Disordered Breathing Destabilizes Ventricular Repolarization. medRxiv 2024:2023.02.10.23285789. [PMID: 36824787 PMCID: PMC9949208 DOI: 10.1101/2023.02.10.23285789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Rationale Sleep-disordered breathing (SDB) increases the risk of cardiac arrhythmias and sudden cardiac death. Objectives To characterize the associations between SDB, intermittent hypoxemia, and the beat-to-beat QT variability index (QTVI), a measure of ventricular repolarization lability associated with a higher risk for cardiac arrhythmias, sudden cardiac death, and mortality. Methods Three distinct cohorts were used for the current study. The first cohort, used for cross-sectional analysis, was a matched sample of 122 participants with and without severe SDB. The second cohort, used for longitudinal analysis, consisted of a matched sample of 52 participants with and without incident SDB. The cross-sectional and longitudinal cohorts were selected from the Sleep Heart Health Study participants. The third cohort comprised 19 healthy adults exposed to acute intermittent hypoxia and ambient air on two separate days. Electrocardiographic measures were calculated from one-lead electrocardiograms. Results Compared to those without SDB, participants with severe SDB had greater QTVI (-1.19 in participants with severe SDB vs. -1.43 in participants without SDB, P = 0.027), heart rate (68.34 vs. 64.92 beats/minute; P = 0.028), and hypoxemia burden during sleep as assessed by the total sleep time with oxygen saturation less than 90% (TST90; 11.39% vs. 1.32%, P < 0.001). TST90, but not the frequency of arousals, was a predictor of QTVI. QTVI during sleep was predictive of all-cause mortality. With incident SDB, mean QTVI increased from -1.23 to -0.86 over 5 years (P = 0.017). Finally, exposing healthy adults to acute intermittent hypoxia for four hours progressively increased QTVI (from -1.85 at baseline to -1.64 after four hours of intermittent hypoxia; P = 0.016). Conclusions Prevalent and incident SDB are associated with ventricular repolarization instability, which predisposes to ventricular arrhythmias and sudden cardiac death. Intermittent hypoxemia destabilizes ventricular repolarization and may contribute to increased mortality in SDB.
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Affiliation(s)
- Soroosh Solhjoo
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- F. Edward Hébert School of Medicine, Bethesda, Maryland, USA
| | - Mark C. Haigney
- F. Edward Hébert School of Medicine, Bethesda, Maryland, USA
- Military Cardiovascular Outcomes Research (MiCOR), Bethesda, Maryland, USA
| | | | - Abigail Koch
- University of Miami Miller School of Medicine, Miami, Florida, USA
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Xu J, Haigney MC, Levine BD, Dineen EH. The Tactical Athlete: Definitions, Cardiovascular Assessment, and Management, and "Fit for Duty" Standards. Card Electrophysiol Clin 2024; 16:93-105. [PMID: 38280817 DOI: 10.1016/j.ccep.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Tactical athletes are individuals in the military, law enforcement, and other professions whose occupations have significant physical fitness requirements coupled with the potential for exposure to life-threatening situations. Such exposures can have varied hemodynamic effects on the cardiovascular system. It is crucial that their clinical evaluation is inclusive of specific occupational requirements. Safety protocols regarding medical clearance are relatively more stringent for this population than for competitive athletes due to the increased impact to the tactical athlete, their team, and the population they aim to serve and protect should they experience a cardiovascular event on the job.
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Affiliation(s)
- Jennifer Xu
- University of California Irvine Medical Center, 333 City Boulevard West, Suite 400, Orange, CA 92868-3298, USA
| | - Mark C Haigney
- Military Cardiovascular Outcomes Research, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, The University of Texas Southwestern Medical Center, 7232 Greenville Avenue, Suite 435, Dallas, TX 75231, USA
| | - Elizabeth H Dineen
- Department of Cardiovascular Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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4
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Gutierrez-Colina AM, Aichele S, Lavender JM, Sanchez N, Thorstad I, Gulley LD, Emerick JE, Schrag R, Thomas V, Spinner H, Arnold T, Heroy A, Haigney MC, Tanofsky-Kraff M, Shomaker LB. Associations of social and cognitive-behavioral variables with disinhibited eating and anxiety: An ecological momentary assessment study. Int J Eat Disord 2024. [PMID: 38415929 DOI: 10.1002/eat.24177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVE Among adolescents, disinhibited eating and anxiety commonly co-occur. Precision intervention approaches targeting unique mechanistic vulnerabilities that contribute to disinhibited eating and anxiety may therefore be helpful. However, the effectiveness of such interventions hinges on knowledge of between- and within-person associations related to disinhibited eating, anxiety, and related processes. METHOD A sample of 39 adolescent females (12-17 years) with elevated anxiety and above-average weight (BMI %ile ≥ 75th) completed measures of theoretically driven social and cognitive-behavioral variables, disinhibited eating, and anxiety via ecological momentary assessment over 7 days. Data were analyzed using mixed-effects models. RESULTS Between-person differences in social stressors were linked to emotional eating, eating in the absence of hunger, and anxiety, whereas between-person differences in negative thoughts were associated with all disinhibited eating variables and anxiety. Between-person differences in avoidance were not related to any outcome. Additionally, between-person differences in social stressors and negative thoughts-as well as within-person deviations (from person-average levels) of social stressors, negative thoughts, and avoidance-were associated with anxiety. In turn, between-person differences in anxiety predicted eating in the absence of hunger and emotional eating, and within-person deviations in anxiety were associated with emotional eating at any given time point. DISCUSSION Findings support elements of both the interpersonal and cognitive-behavioral models of disinhibited eating. Differential trigger effects on anxiety, both at the between- and within-person levels, and significant associations between anxiety and all eating-related outcomes, highlight the potential utility of interventions targeting individual differences in sensitivity to anxiety triggers. PUBLIC SIGNIFICANCE Findings provide support for the interpersonal and cognitive-behavioral models of disinhibited eating, highlighting anxiety as a salient vulnerability and potential mechanistic factor underlying disinhibited eating. Social, cognitive, and behavioral variables were differentially related to anxiety across participants, suggesting potential for future intervention tailoring and intervention selection based on adolescents' sensitivity to anxiety as a trigger for disinhibited eating behavior.
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Affiliation(s)
- Ana M Gutierrez-Colina
- Department of Human Development and Family Studies, Colorado State University, Fort Collins, Colorado, USA
- Department of Pediatrics, Section of Endocrinology, University of Colorado Anschutz and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Stephen Aichele
- Department of Human Development and Family Studies, Colorado State University, Fort Collins, Colorado, USA
- Colorado School of Public Health, Aurora, Colorado, USA
| | - Jason M Lavender
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- The Metis Foundation, San Antonio, Texas, USA
- Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Natalia Sanchez
- Department of Human Development and Family Studies, Colorado State University, Fort Collins, Colorado, USA
| | - Isabel Thorstad
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- The Metis Foundation, San Antonio, Texas, USA
| | - Lauren D Gulley
- Department of Human Development and Family Studies, Colorado State University, Fort Collins, Colorado, USA
- Department of Pediatrics, Section of Endocrinology, University of Colorado Anschutz and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jill E Emerick
- Department of Pediatrics, Uniformed Services University, Bethesda, Maryland, USA
| | - Ruby Schrag
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- The Metis Foundation, San Antonio, Texas, USA
| | - Victoria Thomas
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- The Metis Foundation, San Antonio, Texas, USA
| | - Holly Spinner
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- The Metis Foundation, San Antonio, Texas, USA
| | - Thomas Arnold
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- The Metis Foundation, San Antonio, Texas, USA
| | - Andrew Heroy
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- The Metis Foundation, San Antonio, Texas, USA
| | - Mark C Haigney
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Marian Tanofsky-Kraff
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- Department of Medical and Clinical Psychology, Uniformed Services University, Bethesda, Maryland, USA
| | - Lauren B Shomaker
- Department of Human Development and Family Studies, Colorado State University, Fort Collins, Colorado, USA
- Department of Pediatrics, Section of Endocrinology, University of Colorado Anschutz and Children's Hospital Colorado, Aurora, Colorado, USA
- Colorado School of Public Health, Aurora, Colorado, USA
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Roger VL, Banaag A, Korona-Bailey J, Wiley TMP, Turner CE, Haigney MC, Koehlmoos TP. Prevalence of Heart Failure Stages in a Universal Health Care System: The Military Health System Experience. Am J Med 2023; 136:1079-1086.e1. [PMID: 37481019 PMCID: PMC10592056 DOI: 10.1016/j.amjmed.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Morbidity and mortality related to heart failure are increasing and disparities are widening. These alarming trends, often confounded by access to care, are poorly understood. This study evaluates the prevalence of all stages of heart failure by race and socioeconomic status in an environment with no access barrier to care. METHODS We conducted a cross-sectional observational study of adult beneficiaries aged 18 to 64 years of the Military Health System (MHS), a model for universal health care for fiscal years 2018-2019. We calculated prevalence of preclinical (stages A/B) or clinical (stages C/D) heart failure stages as defined by professional guidelines. Results were analyzed by age, race, and socioeconomic status (using military rank as a proxy). RESULTS Among 5,440,761 MHS beneficiaries aged 18 to 64 years, prevalence of preclinical and clinical heart failure was 18.1% and 2.5%, respectively. Persons with preclinical heart failure were middle aged, with similar proportions of men and women, while those with heart failure were older, mainly men. After multivariable adjustment, male sex (1.35 odds ratio [OR] [preclinical]; 1.95 OR [clinical]), Black race (1.64 OR [preclinical]; 1.88 OR [clinical]) and lower socioeconomic status were significantly associated with large increases in the prevalence of all stages of heart failure. CONCLUSION All stages of heart failure are highly prevalent among MHS beneficiaries of working age and, in an environment with no access barrier to care, there are striking disparities by race and socioeconomic status. The high prevalence of preclinical heart failure, particularly notable among Black beneficiaries, delineates a critical time window for prevention.
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Affiliation(s)
- Véronique L Roger
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Md.
| | - Amanda Banaag
- Uniformed Services University of the Health Science, Bethesda, Md; Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Md
| | - Jessica Korona-Bailey
- Uniformed Services University of the Health Science, Bethesda, Md; Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Md
| | - Tiffany M Powell Wiley
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Md; National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Md
| | - Clesson E Turner
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Md
| | - Mark C Haigney
- Military Cardiovascular Outcomes Research, Cardiology Division, Uniformed Services University, Bethesda Md
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Bauman V, Sanchez N, Repke HE, Spinner H, Thorstad I, Gulley LD, Mains AM, Lavender JM, Thompson KA, Emerick JE, Thomas V, Arnold TB, Heroy A, Gutierrez-Colina AM, Haigney MC, Shomaker LB, Tanofsky-Kraff M. Loss of control eating in relation to blood pressure among adolescent girls with elevated anxiety at-risk for excess weight gain. Eat Behav 2023; 50:101773. [PMID: 37343482 DOI: 10.1016/j.eatbeh.2023.101773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
Loss of control (LOC)-eating, excess weight, and anxiety are robustly linked, and are independently associated with markers of poorer cardiometabolic health, including hypertension. However, no study has examined whether frequency of LOC-eating episodes among youth with anxiety symptoms and elevated weight status may confer increased risk for hypertension. We examined the relationship between LOC-eating frequency and blood pressure among 39 adolescent girls (14.9 ± 1.8 years; body mass index [BMI] = 29.9 ± 5.6; 61.5 % White; 20.5 % African American/Black; 5 % Multiple Races; 2.5 % Asian; 12.8 % Hispanic/Latino; 30.8 % with reported LOC-eating) with elevated anxiety and above average BMI who enrolled in a clinical trial aimed at preventing excess weight gain. LOC-eating over the past three months was assessed via clinical interview, and blood pressure (systolic and diastolic) was measured with an automatic blood pressure monitor. Adjusting for age, fat mass, and height, LOC-eating episode frequency was significantly, positively associated with diastolic blood pressure (β = 0.38, p = 0.02), but not with systolic blood pressure (β = 0.13, p = 0.41). Replication studies, with larger sample sizes, participants of varying weight-strata, and prospective data are required to elucidate the relationship between LOC-eating and cardiovascular functioning in youth with elevated anxiety.
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Affiliation(s)
- Viviana Bauman
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA; The Metis Foundation, San Antonio, TX 78216, USA
| | - Natalia Sanchez
- Department of Human Development and Family Studies, Colorado State University, Fort Collins, CO 80523, USA
| | - Hannah E Repke
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA; The Metis Foundation, San Antonio, TX 78216, USA
| | - Holly Spinner
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA; The Metis Foundation, San Antonio, TX 78216, USA
| | - Isabel Thorstad
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA; The Metis Foundation, San Antonio, TX 78216, USA
| | - Lauren D Gulley
- Department of Human Development and Family Studies, Colorado State University, Fort Collins, CO 80523, USA; Department of Pediatrics, Section of Endocrinology, University of Colorado Anschutz and Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Autumn M Mains
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA; The Metis Foundation, San Antonio, TX 78216, USA
| | - Jason M Lavender
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA; The Metis Foundation, San Antonio, TX 78216, USA
| | - Katherine A Thompson
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA; The Metis Foundation, San Antonio, TX 78216, USA
| | - Jill E Emerick
- Department of Pediatrics, Uniformed Services University, Bethesda, MD 20814, USA
| | - Victoria Thomas
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA; The Metis Foundation, San Antonio, TX 78216, USA
| | - Thomas B Arnold
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA; The Metis Foundation, San Antonio, TX 78216, USA
| | - Andrew Heroy
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA; The Metis Foundation, San Antonio, TX 78216, USA
| | - Ana M Gutierrez-Colina
- Department of Human Development and Family Studies, Colorado State University, Fort Collins, CO 80523, USA; Department of Pediatrics, Section of Endocrinology, University of Colorado Anschutz and Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Mark C Haigney
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - Lauren B Shomaker
- Department of Human Development and Family Studies, Colorado State University, Fort Collins, CO 80523, USA; Department of Pediatrics, Section of Endocrinology, University of Colorado Anschutz and Children's Hospital Colorado, Aurora, CO 80045, USA; Colorado School of Public Health, Aurora, CO 80045, USA
| | - Marian Tanofsky-Kraff
- Military Cardiovascular Outcomes Research (MiCOR) Program, Department of Medicine, Uniformed Services University, Bethesda, MD 20814, USA; Department of Medical and Clinical Psychology, Uniformed Services University, Bethesda, MD 20814, USA.
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Ranzenhofer LM, Solhjoo S, Crosby RD, Kim BH, Korn R, Koorathota S, Lloyd EC, Walsh BT, Haigney MC. Autonomic indices and loss-of-control eating in adolescents: an ecological momentary assessment study. Psychol Med 2023; 53:4742-4750. [PMID: 35920245 PMCID: PMC10336770 DOI: 10.1017/s0033291722001684] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Loss-of-control (LOC) eating commonly develops during adolescence, and it predicts full-syndrome eating disorders and excess weight gain. Although negative emotions and emotion dysregulation are hypothesized to precede and predict LOC eating, they are rarely examined outside the self-report domain. Autonomic indices, including heart rate (HR) and heart rate variability (HRV), may provide information about stress and capacity for emotion regulation in response to stress. METHODS We studied whether autonomic indices predict LOC eating in real-time in adolescents with LOC eating and body mass index (BMI) ⩾70th percentile. Twenty-four adolescents aged 12-18 (67% female; BMI percentile mean ± standard deviation = 92.6 ± 9.4) who reported at least twice-monthly LOC episodes wore biosensors to monitor HR, HRV, and physical activity for 1 week. They reported their degree of LOC after all eating episodes on a visual analog scale (0-100) using a smartphone. RESULTS Adjusting for physical activity and time of day, higher HR and lower HRV predicted higher self-reported LOC after eating. Parsing between- and within-subjects effects, there was a significant, positive, within-subjects association between pre-meal HR and post-meal LOC rating. However, there was no significant within-subjects effect for HRV, nor were there between-subjects effects for either electrophysiologic variable. CONCLUSIONS Findings suggest that autonomic indices may either be a marker of risk for subsequent LOC eating or contribute to LOC eating. Linking physiological markers with behavior in the natural environment can improve knowledge of illness mechanisms and provide new avenues for intervention.
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Affiliation(s)
- Lisa M Ranzenhofer
- Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Soroosh Solhjoo
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ross D Crosby
- Sanford Center for Biobehavioral Research, Fargo, ND, USA
| | - Brittany H Kim
- Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Rachel Korn
- Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | | | - E Caitlin Lloyd
- Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - B Timothy Walsh
- Columbia University Irving Medical Center, New York, NY, USA
| | - Mark C Haigney
- F. Edward Hébert School of Medicine, Bethesda, MD, USA
- Military Cardiovascular Outcomes Research (MiCOR), Bethesda, MD, USA
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8
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McLeod EV, Walsh JC, Haigney MC, Franzos MA, Hellwig LD. Exertional-Related Sudden Cardiac Death in a Young, Presumed Healthy, and Medically Screened Population: A Military Case Series. Am J Forensic Med Pathol 2023:00000433-990000000-00071. [PMID: 37093871 DOI: 10.1097/paf.0000000000000830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
ABSTRACT Sudden cardiac death (SCD) is defined as death from cardiac causes with loss of consciousness occurring within 1 hour of a change in cardiovascular status. As subset, SCD associated with physical exertion (SCD/E) can be defined as a cardiac event whose symptoms start during or within 1 hour of physical exertion. The US military represents a unique opportunity for studying SCD/E because of medical screening at recruitment, mandatory physical training, an active surveillance system, and centralized autopsy services. Because of medical screening, recruits are presumed healthy, but significant conditions can go undetected. We present 4 diverse cases of SCD/E in the military setting. Sudden cardiac death associated with physical exertion is often the first indication of a serious occult cardiac pathology. Postmortem genetic testing revealed a causative pathogenic mutation in 1 of 4 cases, enabling genetic testing of family members to prevent similar catastrophic loss of life, underscoring the importance of postmortem evaluation including genetic testing. Further investigations will help direct screening and prevention to capture those at risk for SCD. The cases presented in this series are a sample of the diverse etiologies and contexts surrounding SCD/E in the military setting that have been captured by Armed Forces Medical Examiner System.
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Affiliation(s)
- Elizabeth V McLeod
- From the National Capital Consortium, Walter Reed National Military Medical Center, Bethesda, MD
| | - John C Walsh
- Forensic Pathology Investigations, Armed Forces Medical Examiner System, Dover, DE
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9
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Xu J, Haigney MC, Levine BD, Dineen EH. The Tactical Athlete. Cardiol Clin 2023; 41:93-105. [DOI: 10.1016/j.ccl.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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10
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Paul SR, Rosing DR, Haigney MC, Peer CJ, Figg WD, Wiestner A, Sun C. Cardiac toxicity in a pilot study of duvelisib and ibrutinib combination therapy for chronic lymphocytic leukaemia. Br J Haematol 2023; 200:261-263. [PMID: 36366824 PMCID: PMC10681272 DOI: 10.1111/bjh.18558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/26/2022] [Accepted: 10/30/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Shira R Paul
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Douglas R Rosing
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Mark C Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Cody J Peer
- Clinical Pharmacology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - William D Figg
- Clinical Pharmacology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Adrian Wiestner
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Clare Sun
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
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11
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Klein MG, Krantz MJ, Fatima N, Watters A, Colon-Sanchez D, Geiger RM, Goldstein RE, Solhjoo S, Mehler PS, Flagg TP, Haigney MC. Methadone Blockade of Cardiac Inward Rectifier K + Current Augments Membrane Instability and Amplifies U Waves on Surface ECGs: A Translational Study. J Am Heart Assoc 2022; 11:e023482. [PMID: 35658478 PMCID: PMC9238736 DOI: 10.1161/jaha.121.023482] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Methadone is associated with a disproportionate risk of sudden death and ventricular tachyarrhythmia despite only modest inhibition of delayed rectifier K+ current (IKr), the principal mechanism of drug-associated arrhythmia. Congenital defects of inward rectifier K+ current (IK1) have been linked to increased U-wave amplitude on ECG and fatal arrhythmia. We hypothesized that methadone may also be a potent inhibitor of IK1, contributing to delayed repolarization and manifesting on surface ECGs as augmented U-wave integrals. Methods and Results Using a whole-cell voltage clamp, methadone inhibited both recombinant and native IK1 with a half-maximal inhibitory concentration IC50) of 1.5 μmol/L, similar to that observed for IKr block (half-maximal inhibitory concentration of 2.9 μmol/L). Methadone modestly increased the action potential duration at 90% repolarization and slowed terminal repolarization at low concentrations. At higher concentrations, action potential duration at 90% repolarization lengthening was abolished, but its effect on terminal repolarization rose steadily and correlated with increased fluctuations of diastolic membrane potential. In parallel, patient ECGs were analyzed before and after methadone initiation, with 68% of patients having a markedly increased U-wave integral compared with premethadone (lead V3; mean +38%±15%, P=0.016), along with increased QT and TPeak to TEnd intervals, likely reflective of IKr block. Conclusions Methadone is a potent IK1 inhibitor that causes augmentation of U waves on surface ECG. We propose that increased membrane instability resulting from IK1 block may better explain methadone's arrhythmia risk beyond IKr inhibition alone. Drug-induced augmentation of U waves may represent evidence of blockade of multiple repolarizing ion channels, and evaluation of the effect of that agent on IK1 may be warranted.
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Affiliation(s)
- Michael G Klein
- Cardiology Division Department of Medicine Uniformed Services University Bethesda MD
| | - Mori J Krantz
- Denver Health Medical Center Cardiology Division Denver CO.,Department of Medicine University of Colorado School of Medicine Aurora CO.,Chief Science Advisor Cardiac Safety and Cardiovascular Imaging, Clario Inc. Philadelphia PA
| | - Naheed Fatima
- Department of Anatomy, Physiology & Genetics Uniformed Services University Bethesda MD
| | - Ashlie Watters
- ACUTE at Denver Health Denver CO.,Department of Medicine University of Colorado School of Medicine Aurora CO
| | - Dayan Colon-Sanchez
- Psychiatry Division Outpatient Behavioral Health Services, Denver Health, & University of Colorado School of Medicine Denver CO
| | - Robert M Geiger
- Department of Anatomy, Physiology & Genetics Uniformed Services University Bethesda MD
| | - Robert E Goldstein
- Cardiology Division Department of Medicine Uniformed Services University Bethesda MD
| | - Soroosh Solhjoo
- Cardiology Division Department of Medicine Uniformed Services University Bethesda MD.,Military Cardiovascular Outcomes Research (MiCOR) Bethesda MD
| | - Philip S Mehler
- ACUTE at Denver Health Denver CO.,Department of Medicine University of Colorado School of Medicine Aurora CO
| | - Thomas P Flagg
- Department of Anatomy, Physiology & Genetics Uniformed Services University Bethesda MD
| | - Mark C Haigney
- Cardiology Division Department of Medicine Uniformed Services University Bethesda MD.,Military Cardiovascular Outcomes Research (MiCOR) Bethesda MD
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12
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Murphy C, Saperstein A, Klusewitz S, Bartol K, Aun JA, Wessman D, Arnold T, Symons JG, Goldstein RE, Needleman M, Franzos MA, Haigney MC. EFFECTIVE CARDIOVASCULAR SCREENING OF MILITARY RECRUITS REQUIRES AN ELECTROCARDIOGRAM. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02629-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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13
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Aun JA, Haigney MC, Needleman M. ACTIVE DUTY ARMY LINGUIST: A LOSS FOR WORDS, PERHAPS SHORT COUPLED VENTRICULAR FIBRILLATION? J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)03467-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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14
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Denic-Roberts H, Rowley N, Haigney MC, Christenbury K, Barrett J, Thomas DL, Engel LS, Rusiecki JA. Acute and longer-term cardiovascular conditions in the Deepwater Horizon Oil Spill Coast Guard Cohort. Environ Int 2022; 158:106937. [PMID: 34688052 PMCID: PMC8688193 DOI: 10.1016/j.envint.2021.106937] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/25/2021] [Accepted: 10/11/2021] [Indexed: 05/31/2023]
Abstract
INTRODUCTION In 2010, the U.S. Coast Guard (USCG) led a clean-up response to the Deepwater Horizon (DWH) oil spill. Human studies evaluating acute and longer-term cardiovascular conditions associated with oil spill-related exposures are sparse. Thus, we aimed to investigate prevalent and incident cardiovascular symptoms/conditions in the DHW Oil Spill Coast Guard Cohort. METHODS Self-reported oil spill exposures and cardiovascular symptoms were ascertained from post-deployment surveys (n = 4,885). For all active-duty cohort members (n = 45,193), prospective cardiovascular outcomes were classified via International Classification of Diseases, 9th Edition from military health encounter records up to 5.5 years post-DWH. We used log-binomial regression to calculate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) in the cross-sectional analyses and Cox Proportional Hazards regression to calculate adjusted hazard ratios (aHR) and 95% CIs for incident cardiovascular diagnoses during 2010-2015 and stratifying by earlier (2010-2012) and later (2013-2015) time periods. RESULTS Prevalence of chest pain was associated with increasing levels of crude oil exposure via inhalation (aPRhigh vs. none = 2.00, 95% CI = 1.16-3.42, p-trend = 0.03) and direct skin contact (aPRhigh vs. none = 2.72, 95% CI = 1.30-5.16, p-trend = 0.03). Similar associations were observed for sudden heartbeat changes and for being in the vicinity of burning oil exposure. In prospective analyses, responders (vs. non-responders) had an elevated risk for mitral valve disorders during 2013-2015 (aHR = 2.12, 95% CI = 1.15-3.90). Responders reporting ever (vs. never) crude oil inhalation exposure were at increased risk for essential hypertension, particularly benign essential hypertension during 2010-2012 (aHR = 2.00, 95% CI = 1.08-3.69). Responders with crude oil inhalation exposure also had an elevated risk for palpitations during 2013-2015 (aHR = 2.54, 95% CI = 1.36-4.74). Cardiovascular symptoms/conditions aPR and aHR estimates were generally stronger among responders reporting exposure to both crude oil and oil dispersants than among those reporting neither. CONCLUSIONS In this large study of the DWH oil spill USCG responders, self-reported spill clean-up exposures were associated with acute and longer-term cardiovascular symptoms/conditions.
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Affiliation(s)
- Hristina Denic-Roberts
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Oak Ridge Institute for Science and Education, MD, USA
| | - Nicole Rowley
- Department of Laboratory Animal Resources, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Mark C Haigney
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Kate Christenbury
- Social & Scientific Systems, Inc., A DLH Holdings Corp Company ("DLH"), Durham, NC, USA
| | - John Barrett
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Dana L Thomas
- United States Coast Guard Headquarters, Directorate of Health, Safety, and Work Life, Washington, D.C., USA
| | - Lawrence S Engel
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Jennifer A Rusiecki
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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15
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Solhjoo S, Punjabi NM, Ivanescu AE, Crainiceanu C, Gaynanova I, Wicken C, Buckenmaier C, Haigney MC. Methadone Destabilizes Cardiac Repolarization During Sleep. Clin Pharmacol Ther 2021; 110:1066-1074. [PMID: 34287835 DOI: 10.1002/cpt.2368] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/06/2021] [Indexed: 11/09/2022]
Abstract
Methadone, a widely prescribed medication for chronic pain and opioid addiction, is associated with respiratory depression and increased predisposition for torsades de pointes, a potentially fatal arrhythmia. Most methadone-related deaths occur during sleep. The objective of this study was to determine whether methadone's arrhythmogenic effects increase during sleep, with a focus on cardiac repolarization instability using QT variability index (QTVI), a measure shown to predict arrhythmias and mortality. Sleep study data of 24 patients on chronic methadone therapy referred to a tertiary clinic for overnight polysomnography were compared with two matched groups not on methadone: 24 patients referred for overnight polysomnography to the same clinic (clinic group), and 24 volunteers who had overnight polysomnography at home (community group). Despite similar values for heart rate, heart rate variability, corrected QT interval, QTVI, and oxygen saturation (SpO2 ) when awake, patients on methadone had larger QTVI (P = 0.015 vs. clinic, P < 0.001 vs. community) and lower SpO2 (P = 0.008 vs. clinic, P = 0.013 vs. community) during sleep, and the increase in their QTVI during sleep vs. wakefulness correlated with the decrease in SpO2 (r = -0.54, P = 0.013). QTVI positively correlated with methadone dose during sleep (r = 0.51, P = 0.012) and wakefulness (r = 0.73, P < 0.001). High-density ectopy (> 1,000 premature beats per median sleep period), a precursor for torsades de pointes, was uncommon but more frequent in patients on methadone (P = 0.039). This study demonstrates that chronic methadone use is associated with increased cardiac repolarization instability. Methadone's pro-arrhythmic impact may be mediated by sleep-related hypoxemia, which could explain the increased nocturnal mortality associated with this opioid.
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Affiliation(s)
- Soroosh Solhjoo
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Naresh M Punjabi
- Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | | | | | - Cassie Wicken
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Mark C Haigney
- F. Edward Hébert School of Medicine, Bethesda, Maryland, USA.,Military Cardiovascular Outcomes Research (MiCOR), Bethesda, Maryland, USA
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16
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Alcover KC, Ambardar SR, Poltavskiy E, Nasir JM, Janak JC, Howard JT, Walker LE, Haigney MC, Stewart IJ. Traumatic injury and atrial fibrillation among deployed service members. J Cardiovasc Electrophysiol 2021; 32:2590-2594. [PMID: 34197003 DOI: 10.1111/jce.15139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/31/2021] [Accepted: 06/21/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Atrial fibrillation and atrial flutter (AF/AFL), the most common atrial arrhythmias, have never been examined in combat casualties. In this study, we investigated the impact of traumatic injury on AF/AFL among service members with deployment history. METHODS Sampled from the Department of Defense (DoD) Trauma Registry (n = 10,000), each injured patient in this retrospective cohort study was matched with a non-injured service member drawn from the Veterans Affairs/DoD Identity Repository. The primary outcome was AF/AFL diagnosis identified using ICD-9-CM and ICD-10-CM codes. Competing risk regressions based on Fine and Gray subdistribution hazards model with were utilized to assess the association between injury and AF/AFL. RESULTS There were 130 reported AF/AFL cases, 90 of whom were injured and 40 were non-injured. The estimated cumulative incidence rates of AF/AFL for injured was higher compared to non-injured patients (hazards ratio [HR] = 2.04; 95% confidence interval [CI] = 1.44, 2.87). After adjustment demographics and tobacco use, the association did not appreciably decrease (HR = 1.90; 95% CI = 1.23, 2.93). Additional adjustment for obesity, hypertension, diabetes, and vascular disorders, the association between injury and AF/AFL was no longer statistically significant (HR = 1.51; 95% CI = 0.99, 2.52). CONCLUSION Higher AF/AFL incidence rate was observed among deployed service members with combat injury compared to servicemembers without injury. The association did not remain significant after adjustment for cardiovascular-related covariates. These findings highlight the need for combat casualty surveillance to further understand the AF/AFL risk within the military population and to elucidate the potential underlying pathophysiologic mechanisms.
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Affiliation(s)
- Karl C Alcover
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Shiva R Ambardar
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Eduard Poltavskiy
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis AFB, California, USA
| | - Javed M Nasir
- Division of Cardiology, Mercy Medical Center, Redding, Virginia, USA
| | | | - Jeffrey T Howard
- Department of Public Health, University of Texas San Antonio, San Antonio, Texas, USA
| | - Lauren E Walker
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis AFB, California, USA
| | - Mark C Haigney
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Military Cardiovascular Outcomes Research (MiCOR), Uniformed Services University, Bethesda, Maryland, USA
| | - Ian J Stewart
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Military Cardiovascular Outcomes Research (MiCOR), Uniformed Services University, Bethesda, Maryland, USA
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17
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Nazari MA, Rosenblum JS, Haigney MC, Rosing DR, Pacak K. Pathophysiology and Acute Management of Tachyarrhythmias in Pheochromocytoma: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 76:451-464. [PMID: 32703516 DOI: 10.1016/j.jacc.2020.04.080] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/11/2020] [Accepted: 04/02/2020] [Indexed: 12/18/2022]
Abstract
Pheochromocytomas, arising from chromaffin cells, produce catecholamines, epinephrine and norepinephrine. The tumor biochemical phenotype is defined by which of these exerts the greatest influence on the cardiovascular system when released into circulation in high amounts. Action on the heart and vasculature can cause potentially lethal arrhythmias, often in the setting of comorbid blood pressure derangements. In a review of electrocardiograms obtained on pheochromocytoma patients (n = 650) treated at our institution over the last decade, severe and refractory sinus tachycardia, atrial fibrillation, and ventricular tachycardia were found to be the most common or life-threatening catecholamine-induced tachyarrhythmias. These arrhythmias, arising from catecholamine excess rather than from a primary electrophysiologic substrate, require special considerations for treatment and complication avoidance. Understanding the synthesis and release of catecholamines, the adrenoceptors catecholamines bind to, and the cardiac and vascular response to epinephrine and norepinephrine underlies optimal management in catecholamine-induced tachyarrhythmias.
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Affiliation(s)
- Matthew A Nazari
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; Department of Internal Medicine and Pediatrics, MedStar Georgetown University Hospital, Washington, DC. https://twitter.com/NazariMatthew
| | - Jared S Rosenblum
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Mark C Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Division of Cardiology, Department of Medicine, Walter Reed National Military Medical Center, and Herbert School of Medicine, Bethesda, Maryland
| | - Douglas R Rosing
- Division of Cardiology, Department of Medicine, Walter Reed National Military Medical Center, and Herbert School of Medicine, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
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18
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Geiger R, Fatima N, Schooley JF, Smyth JT, Haigney MC, Flagg TP. Novel cholesterol-dependent regulation of cardiac K ATP subunit expression revealed using histone deacetylase inhibitors. Physiol Rep 2021; 8:e14675. [PMID: 33356020 PMCID: PMC7757372 DOI: 10.14814/phy2.14675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/18/2020] [Indexed: 12/16/2022] Open
Abstract
We recently discovered that the histone deacetylase inhibitor, trichostatin A (TSA), increases expression of the sulfonylurea receptor 2 (SUR2; Abcc9) subunit of the ATP-sensitive K+ (KATP ) channel in HL-1 cardiomyocytes. Interestingly, the increase in SUR2 was abolished with exogenous cholesterol, suggesting that cholesterol may regulate channel expression. In the present study, we tested the hypothesis that TSA increases SUR2 by depleting cholesterol and activating the sterol response element binding protein (SREBP) family of transcription factors. Treatment of HL-1 cardiomyocytes with TSA (30 ng/ml) caused a time-dependent increase in SUR2 mRNA expression that correlates with the time course of cholesterol depletion assessed by filipin staining. Consistent with the cholesterol-dependent regulation of SREBP increasing SUR2 mRNA expression, we observe a significant increase in SREBP cleavage and translocation to the nucleus following TSA treatment that is inhibited by exogenous cholesterol. Further supporting the role of SREBP in mediating the effect of TSA on KATP subunit expression, SREBP1 significantly increased luciferase reporter gene expression driven by the upstream SUR2 promoter. Lastly, HL-1 cardiomyocytes treated with the SREBP inhibitor PF429242 significantly suppresses the effect of TSA on SUR2 gene expression. These results demonstrate that SREBP is an important regulator of KATP channel expression and suggest a novel method by which hypercholesterolemia may exert negative effects on the cardiovascular system, namely, by suppressing expression of the KATP channel.
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Affiliation(s)
- Robert Geiger
- Department of Anatomy, Physiology, and GeneticsUniformed Services University for the Health SciencesBethesdaMDUSA
| | - Naheed Fatima
- Department of Anatomy, Physiology, and GeneticsUniformed Services University for the Health SciencesBethesdaMDUSA
| | - James F. Schooley
- Department of Anatomy, Physiology, and GeneticsUniformed Services University for the Health SciencesBethesdaMDUSA
| | - Jeremy T. Smyth
- Department of Anatomy, Physiology, and GeneticsUniformed Services University for the Health SciencesBethesdaMDUSA
| | - Mark C. Haigney
- Department of MedicineUniformed Services University for the Health SciencesBethesdaMDUSA
| | - Thomas P. Flagg
- Department of Anatomy, Physiology, and GeneticsUniformed Services University for the Health SciencesBethesdaMDUSA
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19
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Geiger RM, Klein MG, Fatima N, Goldstein RE, Krantz MJ, Haigney MC, Flagg TP. Rapid Assessment of Proarrhythmic Potential Using Human iPSC-Derived Cardiomyocytes. JACC Clin Electrophysiol 2020; 6:1860-1862. [PMID: 33357585 PMCID: PMC7758727 DOI: 10.1016/j.jacep.2020.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/14/2020] [Accepted: 08/28/2020] [Indexed: 10/31/2022]
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20
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Needleman M, Symons J, Weber LA, Mulreany M, May J, Haigney MC. Novel use of an atrial sensing leadless pacemaker to treat complete heart block in a patient with repaired tetralogy of Fallot with pre-existing dual-chamber pacemaker with ventricular lead fracture. HeartRhythm Case Rep 2020; 6:777-781. [PMID: 33101954 PMCID: PMC7573471 DOI: 10.1016/j.hrcr.2020.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Matthew Needleman
- Department of Cardiology, Walter Reed National Military Medical Center, Bethesda, Maryland
- Address reprint requests and correspondence: Dr Matthew Needleman, Department of Cardiology, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889.
| | - John Symons
- Department of Cardiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Lauren A. Weber
- Department of Cardiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Michael Mulreany
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Joseph May
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Mark C. Haigney
- Department of Cardiology, Uniformed Services University of Health Sciences, Bethesda, Maryland
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21
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Segre EM, Hellwig LD, Turner C, Dobson CP, Haigney MC. Exercise Dose Associated With Military Service: Implications for the Clinical Management of Inherited Risk for Arrhythmogenic Right Ventricular Cardiomyopathy. Mil Med 2020; 185:e1447-e1452. [PMID: 32666089 DOI: 10.1093/milmed/usaa185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION High levels of aerobic exercise in individuals who have a gene mutation associated with arrhythmogenic right ventricular cardiomyopathy (ARVC) are associated with clinical disease progression. Guidelines consequently restrict patients from competitive athletics. However, there is minimal literature to guide the safe dosing of physical activity outside of the setting of competitive athletics. Patients may be physically active pursuant to a variety of careers, including military service. This study aimed to define a therapeutic window for exercise for ARVC gene-positive individuals that are compatible with continuing military service and general health while maintaining a level of exercise below that which risks disease progression. MATERIALS AND METHODS Using standard metabolic equations, we calculated the minimum VO2 max (amount of oxygen utilized at peak exercise capacity) required to pass the physical fitness tests for each branch. We then developed a sample exercise prescription to maintain this level of fitness. We compared the prescribed exercise load with the physical activity levels associated with non-inferior clinical outcomes in ARVC gene-positive individuals. Additionally, we determined the physical activity exposure sustained by service members based on self-report data and compared these values with the upper limit of safe exercise exposure. RESULTS Based on a review of the currently available literature, aerobic exercise exposure less than 700 to 1,100 MET-hours/year (metabolic equivalent-hours per year) is not associated with inferior clinical outcomes for gene-positive individuals. A military service member needs 600 to 700 MET-hours/year to minimally pass the physical fitness test. However, many military members are exercising in excess of this minimum, with typical exposures between 900 and 2,400 MET-hours/year. CONCLUSIONS A therapeutic window of aerobic exercise may exist for ARVC gene-positive individuals which would allow continuation of military service while maintaining levels of exercise restriction associated with non-inferior clinical outcomes.
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Affiliation(s)
- Elena M Segre
- Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889
| | - Lydia D Hellwig
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr, Bethesda, MD 20817
| | - Clesson Turner
- Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889
| | - Craig P Dobson
- Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Mark C Haigney
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
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22
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Magee C, Haigney MC. Cardiovascular Screening in the U.S. Military: Time to Reconsider the Electrocardiogram. Mil Med 2020; 185:e1039-e1045. [PMID: 32065233 DOI: 10.1093/milmed/usaa002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/08/2019] [Accepted: 01/04/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The US Department of Defense (DoD) has adopted a model concept of the warrior athlete. Identifying latent disease that could compromise the military operator is critical to the warrior athlete concept. Cardiovascular complaints are the important problem recognized in service members evacuated from combat zones, and the incidence of sudden cardiac death in U.S. military recruits is comparable to or greater than that among National Collegiate Athletic Association Athletes. Nevertheless, the mandatory electrocardiogram (ECG) was removed from official U.S. military accession screening policy in 2002. Inclusion of ECG screening in high risk athletics is increasingly recognized as appropriate by professional organizations such as the American Heart Association and American Medical Society for Sports Medicine, though neither recommends ECG for generalized screening in large, low-risk populations. MATERIALS AND METHODS The appropriate DoD instructions were reviewed in the context of recent literature regarding the sensitivity and specificity of ECG screening for prevention of sudden cardiac arrest or debilitating arrhythmias. RESULTS Challenges to implementation of ECG as a screening modality in U.S. military accessions include clinician interpretation validity and reliability. Modern interpretation criteria and new interpretation technology each serve to mitigate these recognized limitations. Outside experience with implementation of modern ECG suggest potential benefits are significant in the highest risk military groups. CONCLUSION Prospective study of ECG screening is needed to determine the impact on cardiovascular outcomes in U.S. military populations.
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Affiliation(s)
- Charles Magee
- Department of Medicine, University of Virginia, Charlottesville, VA 22903
| | - Mark C Haigney
- Department of Medicine, Division of Cardiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814.,Military Cardiovascular Outcomes Research (MiCOR), Bethesda, MD 20814
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23
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Plavelil N, Goldstein R, Klein M, Ho VB, Haigney MC, Hood MN. Tachycardia‐Induced Matrix Metalloproteinases Activation Associated with Collagen Type III Cardiac Fibrosis and Heart Failure in Swine. FASEB J 2020. [DOI: 10.1096/fasebj.2020.34.s1.08987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Nisha Plavelil
- Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine
| | - Robert Goldstein
- Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine
| | - Michael Klein
- Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine
| | - Vincent B. Ho
- Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine
| | - Mark C. Haigney
- Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine
| | - Maureen N. Hood
- Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine
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Solhjoo S, Haigney MC, McBee E, van Merrienboer JJG, Schuwirth L, Artino AR, Battista A, Ratcliffe TA, Lee HD, Durning SJ. Heart Rate and Heart Rate Variability Correlate with Clinical Reasoning Performance and Self-Reported Measures of Cognitive Load. Sci Rep 2019; 9:14668. [PMID: 31604964 PMCID: PMC6789096 DOI: 10.1038/s41598-019-50280-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 09/05/2019] [Indexed: 01/05/2023] Open
Abstract
Cognitive load is a key mediator of cognitive processing that may impact clinical reasoning performance. The purpose of this study was to gather biologic validity evidence for correlates of different types of self-reported cognitive load, and to explore the association of self-reported cognitive load and physiologic measures with clinical reasoning performance. We hypothesized that increased cognitive load would manifest evidence of elevated sympathetic tone and would be associated with lower clinical reasoning performance scores. Fifteen medical students wore Holter monitors and watched three videos depicting medical encounters before completing a post-encounter form and standard measures of cognitive load. Correlation analysis was used to investigate the relationship between cardiac measures (mean heart rate, heart rate variability and QT interval variability) and self-reported measures of cognitive load, and their association with clinical reasoning performance scores. Despite the low number of participants, strong positive correlations were found between measures of intrinsic cognitive load and heart rate variability. Performance was negatively correlated with mean heart rate, as well as single-item cognitive load measures. Our data signify a possible role for using physiologic monitoring for identifying individuals experiencing high cognitive load and those at risk for performing poorly during clinical reasoning tasks.
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Affiliation(s)
- Soroosh Solhjoo
- Division of Cardiovascular Pathology, Johns Hopkins University School of Medicine, Baltimore, USA.
| | - Mark C Haigney
- Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of The Health Sciences, Bethesda, USA
| | - Elexis McBee
- Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of The Health Sciences, Naval Medical Center, San Diego, USA
| | | | - Lambert Schuwirth
- Prideaux Centre for Research in Health Professions Education, Flinders University, Bedford Park, Australia
| | - Anthony R Artino
- Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of The Health Sciences, Bethesda, USA
| | - Alexis Battista
- Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of The Health Sciences, Bethesda, USA
| | - Temple A Ratcliffe
- Department of Medicine, University of Texas Health Science Center, San Antonio, USA
| | - Howard D Lee
- San Antonio Uniformed Services Health Education Consortium, San Antonio, USA
| | - Steven J Durning
- Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of The Health Sciences, Bethesda, USA
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Klein MG, Shou M, Stohlman J, Solhjoo S, Haigney M, Tidwell RR, Goldstein RE, Flagg TP, Haigney MC. Role of suppression of the inward rectifier current in terminal action potential repolarization in the failing heart. Heart Rhythm 2017; 14:1217-1223. [PMID: 28396172 DOI: 10.1016/j.hrthm.2017.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The failing heart exhibits an increased arrhythmia susceptibility that is often attributed to action potential (AP) prolongation due to significant ion channel remodeling. The inwardly rectifying K+ current (IK1) has been reported to be reduced, but its contribution to shaping the AP waveform and cell excitability in the failing heart remains unclear. OBJECTIVE The purpose of this study was to define the effect of IK1 suppression on the cardiac AP and excitability in the normal and failing hearts. METHODS We used electrophysiological and pharmacological approaches to investigate IK1 function in a swine tachy-pacing model of heart failure (HF). RESULTS Terminal repolarization of the AP (TRAP; the time constant of the exponential fit to terminal repolarization) was markedly prolonged in both myocytes and arterially perfused wedges from animals with HF. TRAP was increased by 54.1% in HF myocytes (P < .001) and 26.2% in HF wedges (P = .014). The increase in TRAP was recapitulated by the potent and specific IK1 inhibitor, PA-6 (pentamidine analog 6), indicating that IK1 is the primary determinant of the final phase of repolarization. Moreover, we find that IK1 suppression reduced the ratio of effective refractory period to AP duration at 90% of repolarization, permitting re-excitation before full repolarization, reduction of AP upstroke velocity, and likely promotion of slow conduction. CONCLUSION Using an objective measure of terminal repolarization, we conclude that IK1 is the major determinant of the terminal repolarization time course. Moreover, suppression of IK1 prolongs repolarization and reduces postrepolarization refractoriness without marked effects on the overall AP duration. Collectively, these findings demonstrate how IK1 suppression may contribute to arrhythmogenesis in the failing heart.
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Affiliation(s)
- Michael G Klein
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
| | - Matie Shou
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jayna Stohlman
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland
| | - Soroosh Solhjoo
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Myles Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Richard R Tidwell
- Department of Pathology and Laboratory Medicine, School of Medicine, The University of North Carolina, Chapel Hill, North Carolina
| | - Robert E Goldstein
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Thomas P Flagg
- Department of Anatomy, Physiology and Genetics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Mark C Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Docekal JW, Haigney MC, Lee JC, Needleman M. Repeat inappropriate defibrillator discharges following defibrillator implantation. What is the mechanism and treatment? HeartRhythm Case Rep 2016; 2:448-450. [PMID: 28491731 PMCID: PMC5419968 DOI: 10.1016/j.hrcr.2016.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
Synthetic opioid agents have been used in modern medicine for over a century and for opioid addiction treatment for over a half-century. Liberal use of opioids in the United States has been attended by an extraordinary increase in opioid-related mortality, with over 16,000 deaths in 2012. As there have been advances in opioid agents for pain and addiction, so have there been advances in our understanding of the cardiac effects of these agents. In the last 10 years, significant data regarding electrophysiologic effects of these agents have been collected. We aim in this review to discuss the effects on cardiac electrophysiology of the various opioid agents currently in use and the evidence that these effects are contributing to the rise in opioid-related mortality.
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Affiliation(s)
| | - Mark C Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, A3060, USUHS, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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Fatima N, Cohen DC, Sukumar G, Sissung TM, Schooley JF, Haigney MC, Claycomb WC, Cox RT, Dalgard CL, Bates SE, Flagg TP. Histone deacetylase inhibitors modulate KATP subunit transcription in HL-1 cardiomyocytes through effects on cholesterol homeostasis. Front Pharmacol 2015; 6:168. [PMID: 26321954 PMCID: PMC4534802 DOI: 10.3389/fphar.2015.00168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/27/2015] [Indexed: 11/29/2022] Open
Abstract
Histone deacetylase inhibitors (HDIs) are under investigation for the treatment of a number of human health problems. HDIs have proven therapeutic value in refractory cases of cutaneous T-cell lymphoma. Electrocardiographic ST segment morphological changes associated with HDIs were observed during development. Because ST segment morphology is typically linked to changes in ATP sensitive potassium (KATP) channel activity, we tested the hypothesis that HDIs affect cardiac KATP channel subunit expression. Two different HDIs, romidepsin and trichostatin A, caused ~20-fold increase in SUR2 (Abcc9) subunit mRNA expression in HL-1 cardiomyocytes. The effect was specific for the SUR2 subunit as neither compound causes a marked change in SUR1 (Abcc8) expression. Moreover, the effect was cell specific as neither HDI markedly altered KATP subunit expression in MIN6 pancreatic β-cells. We observe significant enrichment of the H3K9Ac histone mark specifically at the SUR2 promoter consistent with the conclusion that chromatin remodeling at this locus plays a role in increasing SUR2 gene expression. Unexpectedly, however, we also discovered that HDI-dependent depletion of cellular cholesterol is required for the observed effects on SUR2 expression. Taken together, the data in the present study demonstrate that KATP subunit expression can be epigenetically regulated in cardiomyocytes, defines a role for cholesterol homeostasis in mediating epigenetic regulation and suggests a potential molecular basis for the cardiac effects of the HDIs.
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Affiliation(s)
- Naheed Fatima
- Department of Anatomy, Physiology and Genetics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences Bethesda, MD, USA
| | - Devin C Cohen
- Department of Anatomy, Physiology and Genetics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences Bethesda, MD, USA
| | - Gauthaman Sukumar
- Department of Anatomy, Physiology and Genetics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences Bethesda, MD, USA
| | - Tristan M Sissung
- Developmental Therapeutic Branch, National Cancer Institute, National Institutes of Health Bethesda, MD, USA
| | - James F Schooley
- Department of Anatomy, Physiology and Genetics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences Bethesda, MD, USA
| | - Mark C Haigney
- Department of Medicine, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences Bethesda, MD, USA
| | - William C Claycomb
- Department of Biochemistry and Molecular Biology, LSU Health Sciences Center New Orleans, LA, USA
| | - Rachel T Cox
- Department of Biochemistry, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences Bethesda, MD, USA
| | - Clifton L Dalgard
- Department of Anatomy, Physiology and Genetics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences Bethesda, MD, USA
| | - Susan E Bates
- Developmental Therapeutic Branch, National Cancer Institute, National Institutes of Health Bethesda, MD, USA
| | - Thomas P Flagg
- Department of Anatomy, Physiology and Genetics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences Bethesda, MD, USA
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Perkiomaki JS, Ruwald AC, Kutyifa V, Ruwald MH, Mcnitt S, Polonsky B, Goldstein RE, Haigney MC, Krone RJ, Zareba W, Moss AJ. Risk factors and the effect of cardiac resynchronization therapy on cardiac and non-cardiac mortality in MADIT-CRT. Europace 2015; 17:1816-22. [PMID: 26071234 DOI: 10.1093/europace/euv201] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/11/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS To understand modes of death and factors associated with the risk for cardiac and non-cardiac deaths in patients with cardiac resynchronization therapy with implantable cardioverter-defibrillator (CRT-D) vs. implantable cardioverter-defibrillator (ICD) therapy, which may help clarify the action and limitations of cardiac resynchronization therapy (CRT) in relieving myocardial dysfunction. METHODS AND RESULTS In Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT), during 4 years of follow-up, 169 (9.3%) of 1820 patients died of known causes, 108 (63.9%) deemed cardiac, and 61 (36.1%) non-cardiac. In multivariate analysis, increased baseline creatinine was significantly associated with both cardiac and non-cardiac deaths [hazard ratio (HR) 2.97, P < 0.001; HR 1.80, P = 0.035, respectively], as was diabetes (HR 1.79, P = 0.006; HR 1.73, P = 0.038, respectively), and the worst New York Heart Association Class > II more than 3 months prior to enrolment (HR 1.90, P = 0.012; HR 2.46, P = 0.010, respectively). Baseline left atrial volume index was significantly associated only with cardiac mortality (HR 1.28 per 5 unit increase, P < 0.001). Ischaemic cardiomyopathy was associated only with non-cardiac death (HR 3.54, P = 0.001). CRT-D vs. an ICD-only was associated with a reduced risk for cardiac death in patients with left bundle branch block (LBBB) (HR 0.56, P = 0.029) but was associated with an increased risk for non-cardiac death in non-LBBB patients (HR 3.48, P = 0.048). CONCLUSIONS In MADIT-CRT, two-thirds of the deaths were cardiac and one-third non-cardiac. Many of the same risk factors were associated with both cardiac and non-cardiac mortalities. CRT-D was associated with a reduced risk for cardiac death in LBBB but an increased risk for non-cardiac death in non-LBBB. CLINICAL TRIAL REGISTRATION Information for the MADIT-CRT main study http://www.clinicaltrials.gov, NCT00180271.
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Affiliation(s)
- Juha S Perkiomaki
- Cardiology Unit, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000 (Kajaanintie 50), FIN-90014 Oulu, Finland
| | - Anne-Christine Ruwald
- Cardiology Unit, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA Department of Cardiology, Gentofte Hospital, Hellerup, Denmark
| | - Valentina Kutyifa
- Cardiology Unit, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Martin H Ruwald
- Cardiology Unit, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA Department of Cardiology, Gentofte Hospital, Hellerup, Denmark
| | - Scott Mcnitt
- Cardiology Unit, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Bronislava Polonsky
- Cardiology Unit, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Robert E Goldstein
- Cardiology Division, Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Mark C Haigney
- Cardiology Division, Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Ronald J Krone
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Wojciech Zareba
- Cardiology Unit, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Arthur J Moss
- Cardiology Unit, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
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Abstract
The finding of QTc prolongation often sounds the death knell for a new molecule, but investigators have long suspected that QTc prolongation alone may be an indifferent predictor of risk. Premature or inappropriate rejection of promising molecules deprives clinicians of new therapies and depletes industry resources. Could it be that the conventional electrocardiogram contains information that might prevent us from relegating "virtuous" compounds to a fate they do not deserve?
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Affiliation(s)
- M C Haigney
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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31
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Chou R, Cruciani RA, Fiellin DA, Compton P, Farrar JT, Haigney MC, Inturrisi C, Knight JR, Otis-Green S, Marcus SM, Mehta D, Meyer MC, Portenoy R, Savage S, Strain E, Walsh S, Zeltzer L. Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain 2014; 15:321-37. [PMID: 24685458 DOI: 10.1016/j.jpain.2014.01.494] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 01/08/2023]
Abstract
UNLABELLED Methadone is used for the treatment of opioid addiction and for treatment of chronic pain. The safety of methadone has been called into question by data indicating a large increase in the number of methadone-associated overdose deaths in recent years that has occurred in parallel with a dramatic rise in the use of methadone for chronic pain. The American Pain Society and the College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned an interdisciplinary expert panel to develop a clinical practice guideline on safer prescribing of methadone for treatment of opioid addiction and chronic pain. As part of the guideline development process, the American Pain Society commissioned a systematic review of various aspects related to safety of methadone. After a review of the available evidence, the expert panel concluded that measures can be taken to promote safer use of methadone. Specific recommendations include the need to educate and counsel patients on methadone safety, use of electrocardiography to identify persons at greater risk for methadone-associated arrhythmia, use of alternative opioids in patients at high risk of complications related to corrected electrocardiographic QTc interval prolongation, careful dose initiation and titration of methadone, and diligent monitoring and follow-up. Although these guidelines are based on a systematic review, the panel identified numerous research gaps, most recommendations were based on low-quality evidence, and no recommendations were based on high-quality evidence. PERSPECTIVE This guideline, based on a systematic review of the evidence on methadone safety, provides recommendations developed by a multidisciplinary expert panel. Safe use of methadone requires clinical skills and knowledge in use of methadone to mitigate potential risks, including serious risks related to risk of overdose and cardiac arrhythmias.
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Affiliation(s)
- Roger Chou
- Departments of Medicine and Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, and Pacific Northwest Evidence-based Practice Center, Portland, Oregon.
| | - Ricardo A Cruciani
- Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York
| | - David A Fiellin
- School of Public Health, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark C Haigney
- Cardiology Uniformed Services, University of the Health Sciences, Baltimore, Maryland
| | - Charles Inturrisi
- Department of Pharmacology, Weill Cornell Medical College, New York, New York
| | - John R Knight
- Center for Adolescent Substance Abuse Research, Children's Hospital Boston, Boston, Massachusetts
| | - Shirley Otis-Green
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope National Medical Center, Duarte, California
| | - Steven M Marcus
- School of Biomedical and Health Sciences, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | - Davendra Mehta
- Departments of Medicine and Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marjorie C Meyer
- Departments of Gynecology and Maternal Fetal Medicine, University of Vermont, Burlington, Vermont
| | - Russell Portenoy
- Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York
| | - Seddon Savage
- Department of Anesthesiology, Dartmouth Medical School, Hanover, New Hampshire
| | - Eric Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon Walsh
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Lonnie Zeltzer
- Pediatric Pain Program, Mattel Children's Hospital at UCLA, Los Angeles, California
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Alampay MM, Haigney MC, Flanagan MC, Perito RM, Love KM, Grammer GG. Transcranial magnetic stimulation as an antidepressant alternative in a patient with Brugada syndrome and recurrent syncope. Mayo Clin Proc 2014; 89:1584-7. [PMID: 25444490 DOI: 10.1016/j.mayocp.2014.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/18/2014] [Accepted: 08/26/2014] [Indexed: 11/26/2022]
Abstract
Brugada syndrome (BrS) is a common occult cause of sudden cardiac arrest in otherwise healthy-appearing adults. The pathognomonic electrocardiographic pattern may be unmasked only by certain medications, many of which are unknown. We report a case of a depressed but otherwise healthy man with an asymptomatic right bundle branch block on electrocardiography who experienced antidepressant-induced BrS and ultimately recovered with transcranial magnetic stimulation (TMS). After an initial trial of nortriptyline, the patient's depressive symptoms improved; however, he experienced a syncopal event and was subsequently diagnosed as having BrS. Cross titration to bupropion, which had not previously been known to exacerbate BrS, was followed by another cardiac event. As a result, the patient was referred for TMS as a substitute for pharmacotherapy. After 31 TMS sessions over 8 weeks, the patient demonstrated significant improvement by subjective report and objective reduction in his Patient Health Questionnaire-9 scores from 10 (moderate) to 1 (minimal). Transcranial magnetic stimulation is a Food and Drug Administration-approved nonpharmacologic treatment for depression. Given the potential lethality of BrS with known and unknown psychopharmacologic agents, providers should consider TMS as first-line therapy in this patient population. Bupropion should be added to the list of agents known to exacerbate this disease.
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Affiliation(s)
- Miguel M Alampay
- Department of Psychiatry, Walter Reed National Military Medical Center, Bethesda, MD.
| | - Mark C Haigney
- Department of Medicine-Cardiology, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Michael C Flanagan
- Department of Cardiology, Fort Belvoir Community Hospital, Fort Belvoir, VA
| | - Robert M Perito
- Department of Psychiatry, Walter Reed National Military Medical Center, Bethesda, MD
| | - Kathleen M Love
- Department of Cardiology, Naval Hospital, Camp Pendleton, CA
| | - Geoffrey G Grammer
- Department of Research, National Intrepid Center of Excellence, Bethesda, MD
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Abstract
BACKGROUND Premature ventricular complexes (PVCs) and ventricular tachycardia (VT) are associated with persistent symptoms and ventricular dysfunction. Approved medical therapies have undesirable side effects and proarrhythmic liability. Ranolazine is a novel antianginal that preferentially blocks the late sodium current. This current is enhanced among patients with cardiomyopathy; a promising target population for ranolazine. The utility of ranolazine, however, for ventricular arrhythmia suppression has not been well characterized. OBJECTIVES We sought to determine the effectiveness of ranolazine for suppression of ventricular ectopy, particularly in the setting of ventricular dysfunction where enhanced efficacy might be expected. METHODS We retrospectively evaluated eight patients (six with >10% PVC burden and two with incessant VT) treated with ranolazine. Arrhythmia frequency was evaluated by continuous monitoring before and after ranolazine initiation and the correlation between ventricular function and reduction in PVC burden was assessed. RESULTS Among six patients with PVCs, ranolazine resulted in a median decrease in PVC burden of 60.2% (P = 0.06). In two cases of apparent PVC-induced cardiomyopathy, normalization of ventricular function was observed. A significant, inverse correlation between baseline ejection fraction and percentage reduction in PVCs was observed (rho = -0.89, P = 0.02). In two patients treated for incessant VT despite Class III antiarrhythmic therapy, ranolazine eliminated VT and prevented recurrent defibrillator therapy. CONCLUSIONS Although not approved for this indication, ranolazine appears effective for symptomatic ventricular arrhythmias. The reduction in PVC burden was greatest among individuals with reduced ventricular function, perhaps due to enhanced late sodium current associated with cardiomyopathy. A confirmatory prospective trial seems warranted.
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Affiliation(s)
- Eric Yeung
- Walter Reed National Military Medical Center, Bethesda, MD
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Wedam EF, Haigney MC. Opioid addiction agonist therapy and the QT prolongation phenomenon: state of the science and evolving research questions. Addiction 2013; 108:1015-7. [PMID: 23659837 DOI: 10.1111/add.12123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Erich F. Wedam
- Division of Cardiology; Department of Medicine; Uniformed Services University of the Health Sciences; Bethesda; MD; USA
| | - Mark C. Haigney
- Division of Cardiology; Department of Medicine; Uniformed Services University of the Health Sciences; Bethesda; MD; USA
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Noonan AM, Eisch RA, Liewehr DJ, Sissung TM, Venzon DJ, Flagg TP, Haigney MC, Steinberg SM, Figg WD, Piekarz RL, Bates SE. Electrocardiographic studies of romidepsin demonstrate its safety and identify a potential role for K(ATP) channel. Clin Cancer Res 2013; 19:3095-104. [PMID: 23589175 DOI: 10.1158/1078-0432.ccr-13-0109] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Romidepsin is a histone deacetylase inhibitor (HDI) approved for the treatment of both cutaneous and peripheral T-cell lymphoma (CTCL and PTCL). During development, a thorough assessment of cardiac toxicity was conducted. EXPERIMENTAL DESIGN A phase II single-agent nonrandomized study of romidepsin was conducted in patients with CTCL or PTCL who had progressed after at least 1 prior systemic therapy. RESULTS Results for the first 42 patients enrolled on the NCI 1312 phase II study of romidepsin in CTCL or PTCL showed no cardiac toxicity based on serial electrocardiograms (ECG), troponins, and MUGA scans/echocardiograms. The cardiac assessments reported herein confirm the safety of romidepsin among 131 enrolled patients, while supporting a role for electrolyte replacement. Heart rate increased an average 11 bpm following romidepsin infusion; there was no evidence of increased arrhythmia. Criteria for potassium/magnesium replacement were met before 55% of 1365 romidepsin doses; an association with hypoalbuminemia was confirmed. We propose a mechanism for ST segment flattening and depression, the most common ECG abnormalities observed: HDI-induced alteration of the activity or expression of KATP channels. In addition, examination of the variants of the active transporter of romidepsin, ABCB1, showed a trend toward smaller heart rate changes in the peri-infusion period among wild-type than variant diplotypes. CONCLUSIONS We conclude that in the context of appropriate attention to electrolyte levels, the data support the cardiac safety of romidepsin.
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MESH Headings
- ATP Binding Cassette Transporter, Subfamily B
- ATP Binding Cassette Transporter, Subfamily B, Member 1/genetics
- Adult
- Aged
- Aged, 80 and over
- Antibiotics, Antineoplastic/adverse effects
- Depsipeptides/adverse effects
- Electrocardiography/drug effects
- Female
- Genotype
- Heart Rate/drug effects
- Histone Deacetylase Inhibitors/adverse effects
- Humans
- Lymphoma, T-Cell, Cutaneous/drug therapy
- Lymphoma, T-Cell, Cutaneous/genetics
- Lymphoma, T-Cell, Cutaneous/metabolism
- Lymphoma, T-Cell, Peripheral/drug therapy
- Lymphoma, T-Cell, Peripheral/genetics
- Lymphoma, T-Cell, Peripheral/metabolism
- Magnesium/blood
- Male
- Middle Aged
- Potassium/blood
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Affiliation(s)
- Anne M Noonan
- Medical Oncology Branch, National Cancer Institute, NIH, Bethesda, Maryland 20892, USA
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Goldstein RE, Haigney MC, Krone RJ, McNitt S, Zareba W, Moss AJ. Differing effects of cardiac resynchronization therapy on long-term mortality in patient subgroups of MADIT-CRT defined by baseline conduction and 1-year post-treatment left ventricular remodeling. Heart Rhythm 2013. [DOI: 10.1016/j.hrthm.2012.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Spevak C, Hamsher C, Brown CQ, Wedam EF, Haigney MC. The clinical significance of QT interval prolongation in anesthesia and pain management: what you should and should not worry about. Pain Med 2012; 13:1072-80. [PMID: 22680349 DOI: 10.1111/j.1526-4637.2012.01406.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The most feared drug-induced complication is fatal cardiac arrest. Torsades de pointes (TdP) is a polymorphic ventricular tachycardia occurring in the setting of a QT interval prolongation and is the most frequent type of drug-induced pro-arrhythmia. The most common mechanism of QT prolongation and TdP is blockade of the rapid component of the delayed rectifier repolarizing potassium conductance IKr. Anesthesiologists have extensive experience with QT prolonging drugs, but there are relatively few reports of TdP occurring in the perioperative setting. Nevertheless, regulatory concern regarding the drug droperidol resulted in a significant reduction in its use. Concern regarding two other agents that potently block IKr, i.e., sevoflurane and methadone, has grown, and practitioners are worried that these valuable agents may meet the same fate. In this review, the data regarding the TdP risk of droperidol, sevoflurane, and methadone are compared with particular emphasis on the different settings in which they are employed. While the three drugs are potent IKr inhibitors, little evidence exists to suggest that droperidol or sevoflurane are associated with significant proarrhythmia in the perioperative setting. Due to factors such as inhibition of the parasympathetic nervous system, prevention of hypoxia and hypercarbia, and attention to serum electrolytes, TdP is a very rare occurrence in the perioperative environment. Methadone, however, is typically given to outpatients, over long periods, and in combination with agents that inhibit its metabolism or are QT prolonging in their own right. Thus, pre- and post-drug electrocardiograms may be appropriate when prescribing methadone for outpatients, while the much lower risk for TdP (and the difficulties inherent in QT measurement in the perioperative period) render this approach unfruitful and worthy of reevaluation.
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Affiliation(s)
- Christopher Spevak
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Haigney MC, Strickberger A. Difficult Decisions in Clinical Electrophysiology-A Case-Based Approach. Card Electrophysiol Clin 2012; 4:xv-xvi. [PMID: 26939825 DOI: 10.1016/j.ccep.2012.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Mark C Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, A3060, USUHS, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Adam Strickberger
- Washington Electrophysiology, 106 Irving Street NW # 204, Washington, DC 20010-2993, USA
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Affiliation(s)
- Mark C Haigney
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Wedam EF, Haigney MC. The thorough QT study: let's be precise. Cardiol J 2011; 18:341-342. [PMID: 21769813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
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Wedam EF, Haigney MC. Bifocal right ventricular pacing: bail-out or cop-out? Cardiol J 2010; 17:1-3. [PMID: 20104450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
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Hanson JL, Broussard JR, Durning SJ, DeGraba TJ, Haigney MC, Fortuin NJ, Williams MS. Evaluation of exercise-induced cerebrovascular accidents after aortic valve replacement. Mayo Clin Proc 2009; 84:558-60. [PMID: 19483174 PMCID: PMC2688631 DOI: 10.4065/84.6.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
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Hanson JL, Broussard JR, Durning SJ, DeGraba TJ, Haigney MC, Fortuin NJ, Williams MS. Evaluation of exercise-induced cerebrovascular accidents after aortic valve replacement. Mayo Clin Proc 2009; 84:558-60. [PMID: 19483174 PMCID: PMC2688631 DOI: 10.1016/s0025-6196(11)60589-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Haigney MC, Kop WJ, Alam S, Krantz DS, Karasik P, DelNegro AA, Gottdiener JS. QT variability during rest and exercise in patients with implantable cardioverter defibrillators and healthy controls. Ann Noninvasive Electrocardiol 2009; 14:40-9. [PMID: 19149792 DOI: 10.1111/j.1542-474x.2008.00274.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Increased QT Variability (QTVI) is predictive of life threatening arrhythmias in vulnerable patients. The predictive value of QTVI is based on resting ECGs, and little is known about the effect of acute exercise on QTVI. The relation between QTVI and arrhythmic vulnerability markers such as T-wave alternans (TWA) has also not been studied. This study examined the effects of exercise on QTVI and TWA in patients with arrhythmic vulnerability. METHODS Digitized ECGs were obtained from 47 ICD patients (43 males; age 60.9 +/- 10.1) and 23 healthy controls (18 males; age 59.7 +/- 9.5) during rest and bicycle exercise. QTVI was assessed using a previously validated algorithm and TWA was measured as both a continuous and a categorical variable based on a priori diagnostic criteria. RESULTS QTVI increased with exercise in ICD patients (-0.79 +/- 0.11 to 0.36 +/- 0.08, P < 0.001) and controls (-1.50 +/- 0.07 to -0.19 +/- 0.12, P < 0.001), and QTVI levels were consistently higher in ICD patients than controls during rest and exercise (P < 0.001). The magnitude of QTVI increase from baseline levels was not larger among ICD patients versus controls (P > 0.20). Among ICD patients, elevated exercise QTVI was related to lower LV ejection fraction and inducibility of ischemia (P < 0.05). QTVI at rest correlated with exercise TWA (r = 0.54, P = 0.0004). CONCLUSIONS QT variability increases significantly with exercise, and exercise QTVI is related to other well-documented markers of arrhythmic vulnerability, including low ejection fraction, inducible ischemia, and TWA. Resting QTVI may be useful in the risk stratification of individuals incapable of performing standard exercise protocols.
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Affiliation(s)
- Mark C Haigney
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Andrews CM, Krantz MJ, Wedam EF, Marcuson MJ, Capacchione JF, Haigney MC. Methadone-induced mortality in the treatment of chronic pain: role of QT prolongation. Cardiol J 2009; 16:210-217. [PMID: 19437394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Methadone is increasingly prescribed for chronic pain, yet the associated mortality appears to be rising disproportionately relative to other opioid analgesics. We review the available evidence on methadone-associated mortality, and explore potential pharmacokinetic and pharmacodynamic explanations for its greater apparent lethality. While methadone shares properties of central nervous system and respiratory depression with other opioids, methadone is unique as a potent blocker of the delayed rectifier potassium ion channel (IKr). This results in QT-prolongation and torsade de pointes (TdP) in susceptible individuals. In some individuals with low serum protein binding of methadone, the extent of blockade is roughly comparable to that of sotalol, a potent QT-prolonging drug. Predicting an individual's propensity for methadone-induced TdP is difficult at present given the inherent limitations of the QT interval as a risk-stratifier combined with the multifactorial nature of the arrhythmia. Consensus recommendations have recently been published to mitigate the risk of TdP until further studies better define the arrhythmia risk factors for methadone. Studies are needed to provide insights into the clinical covariates most likely to result in methadone-associated arrhythmia and to assess the feasibility of current risk mitigation strategies.
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Affiliation(s)
- Christopher M Andrews
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Haigney MC, Zareba W, Nasir JM, McNitt S, McAdams D, Gentlesk PJ, Goldstein RE, Moss AJ. Gender differences and risk of ventricular tachycardia or ventricular fibrillation. Heart Rhythm 2008; 6:180-6. [PMID: 19187907 DOI: 10.1016/j.hrthm.2008.10.045] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Accepted: 10/30/2008] [Indexed: 12/21/2022]
Abstract
BACKGROUND Healthy women have longer QT intervals and more drug-induced proarrhythmia compared to men, yet those given implantable cardioverter-difibrillators (ICDs) for ischemic cardiomyopathy have fewer episodes of ventricular tachycardia/ventricular fibrillation (VT/VF) than men. The role of repolarization duration and stability in arrhythmogenesis in men and women with structural heart disease has not been explored. OBJECTIVES The purpose of this study was to analyze repolarization differences between men and women and their relation to the risk of VT/VF. METHODS Multicenter Automatic Defibrillator Trial II study patients underwent 10-minute, resting digitized recordings at study entry. QT and heart rate were measured for each beat with a semiautomated method. QT variance was normalized for mean QT (QTVN) or for heart rate variance (QTVI). Spectral analysis of heart rate and QT time series was performed; coherence was indexed to quantify consistency of heart rate and QT power spectra. The incidence of VT/VF was determined by ICD interrogation. RESULTS There were 805 usable recordings (142 females); 463 received ICDs (86 females). There was no gender difference in mean or median QT, QTc, or heart rate. QTVN and QTVI were slightly (but significantly) higher, and the mean coherence was lower in women. In a Cox multivariate analysis, increased QTVN or QTVI (top quartile) was associated with a significantly higher risk for VT/VF in men (QTVN hazard ratio (HR) 2.2; confidence interval [CI] 1.4-3.4; P = .001; QTVI HR 1.9; CI 1.2-3.0; P = .006) but not in women, while reduced coherence (bottom quartile) predicted VT/VF in women (HR 3.3; CI 1.2-9.0; P = .021) but not in men. CONCLUSIONS In post-myocardial infarcation patients with depressed ejection fraction, both women and men manifest increased temporal variability in the QT interval. In men, QT variability by itself raised arrhythmic risk. In women, however, QT variability dissociated from HR variability (low coherence) appeared to be a uniquely significant predictor of arrhythmic events.
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Affiliation(s)
- Mark C Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814, USA.
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Abstract
The introduction of new techniques into medical practice frequently results in uncertainty for potential referring physicians and patients alike. The development of safe and effective percutaneous techniques for the cure of symptomatic Wolff-Parkinson-White (WPW) syndrome quickly led to near-elimination of the use of cardiac surgery and antiarrhythmic drugs to treat this proarrhythmic condition, and is justly regarded as a triumph of innovation by both electrophysiologists and biomedical engineers. The introduction of balloon angioplasty also led to a reduction in the number of patients referred for surgical procedures, although with arguably less rationale. An excess of popular enthusiasm among patients and physicians for this procedure made critical debate (continuing in academic circles) moot, at least in the USA. In this paper, I will argue that radiofrequency ablation for the treatment of atrial fibrillation is more akin to the use of angioplasty and less like the treatment of WPW, and cannot be justified as first-line therapy. Unfortunately, excessively optimistic characterization of ablation for atrial fibrillation is obscuring critical issues that ought to be considered by electrophysiologists, referring physicians and patients.
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Affiliation(s)
- Mark C Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA.
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Abstract
The Na+/Ca2+ exchanger (NCX) is an important Ca2+ transport mechanism in virtually all cells in the body. There are three genes that control the expression of NCX in mammals. There are at least 16 alternatively spliced isoforms of NCX1 that target muscle and nerve and other tissues. Here we briefly discuss three remarkable regulatory issues or "conundrums" that involve the most prevalently expressed gene, NCX1. (1) How is NCX1 regulated by phosphorylation? We suggest that the macromolecular complex of NCX1 plays a critical role in the regulation of NCX. The role of the macromolecular complex and evidence supporting its existence and functional importance is presented. (2) Can there be transport block of a single "mode" of NCX1 transport by drugs or therapeutic agents? The simple answer is "no." A brief explanation is provided. (3) How can NCX1 knockout mice live? The answer is "by other compensatory regulatory mechanisms." These conundrums highlight important features in NCX1 and lay the foundation for new experiments to elucidate function and regulation of NCX1 and provide a context for investigations that seek to understand novel therapeutic agents.
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Affiliation(s)
- Abdul M Ruknudin
- Department of Microbiology and Immunology, 660 W. Redwood Street, Baltimore, MD 21201, USA.
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