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Tran MV, Marceau E, Liu Y, Sallam K, Medina P, Liu C, Sayed N, Muller MD, Liang DH, Chen IY. Coronary Artery Vasospasm Requiring Cardiac Autotransplantation Yet Controlled With Tobacco. JACC Case Rep 2021; 3:1177-1181. [PMID: 34401754 PMCID: PMC8353556 DOI: 10.1016/j.jaccas.2021.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 12/28/2020] [Revised: 03/18/2021] [Accepted: 03/25/2021] [Indexed: 11/25/2022]
Abstract
Coronary artery vasospasm is typically managed through avoidance of triggers and with symptomatic treatments with calcium channel blockers and long-acting nitrates. Here, we report a rare case of medically refractory coronary artery vasospasm associated with genetic predispositions that initially required cardiac autotransplantation followed paradoxically by nicotine for long-term symptomatic control. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Matthew V. Tran
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
- Medical Service, Cardiology Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Eric Marceau
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
- Medical Service, Cardiology Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Yu Liu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Karim Sallam
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
- Medical Service, Cardiology Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Pedro Medina
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
- Medical Service, Cardiology Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Chun Liu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Nazish Sayed
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Matthew D. Muller
- Department of Anesthesiology and Perioperative Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - David H. Liang
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
- Dr. David Liang, Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room H-2157, MC5233, Stanford, California 94305-5233, USA.
| | - Ian Y. Chen
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
- Medical Service, Cardiology Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Addresses for correspondence: Dr. Ian Y. Chen, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Suite 111C, Palo Alto, California 94304, USA. @IanChenMD
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2
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Matsushime S, Kuriyama A. Vasopressin for persistent hypotension due to amlodipine and olmesartan overdose: A case report. Ann Med Surg (Lond) 2021; 65:102292. [PMID: 33981424 PMCID: PMC8082198 DOI: 10.1016/j.amsu.2021.102292] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 11/21/2022] Open
Abstract
Background While there are consensus recommendations for managing calcium channel blocker (CCB) toxicity, reports on angiotensin II receptor blocker (ARB) toxicity and management are limited. Herein, we report a case of catecholamine-refractory hypotension due to CCB and ARB overdose. Case presentation A 54-year-old woman with underlying hypertension was brought to the emergency department after she attempted suicide by ingesting 345 mg of amlodipine, a CCB, and 340 mg of olmesartan, an ARB. She was hypotensive, which was considered vasodilatory because of high cardiac and low systemic vascular resistance indices. Hypotension persisted despite the administration of norepinephrine and epinephrine. Intravenous calcium gluconate, glucagon, and high-dose insulin euglycemia therapy, which were initiated because CCB toxicity was suspected, failed to raise her blood pressure. The presence of normal anion-gap metabolic acidosis and the fact that the patient remained hypotensive suggested that the hypotension might have been due to the effect of ARB. Vasopressin was finally administered, which improved her hemodynamic status. She was weaned off all vasopressors on day 3. Discussion There is no consensus recommendation for ARB toxicity. Since chronic use of ARBs at conventional doses can block the sympathetic nervous and renin–angiotensin systems, catecholamines may not effectively increase blood pressure in cases of hypotension due to ARB overdose, for which vasopressin could be indicated. Conclusions Vasopressin could be an option for treating hypotension secondary to ARB and CCB toxicity when catecholamines and treatment for CCB toxicity fail. Chronic use of ARBs blocks the sympathetic nervous and renin–angiotensin systems. There is no consensus recommendation for angiotensin II receptor blocker (ARB) toxicity. Catecholamines may not effectively raise blood pressure in hypotension due to ARB toxicity. Vasopressin could be an option for treating hypotension secondary to ARB toxicity.
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Affiliation(s)
- Susumu Matsushime
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa Kurashiki Okayama, 710-8602, Japan
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa Kurashiki Okayama, 710-8602, Japan
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3
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Eliasson A, Kashani M, Vernalis M. Results of a prospective cardiovascular disease prevention program. Prev Med Rep 2021; 22:101344. [PMID: 33842199 PMCID: PMC8020477 DOI: 10.1016/j.pmedr.2021.101344] [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: 11/25/2020] [Revised: 02/02/2021] [Accepted: 02/22/2021] [Indexed: 12/03/2022] Open
Abstract
The Cardiovascular Health Program (CHP) Registry is a 12-month, prospective study of therapeutic lifestyle change (TLC). Adult participants received comprehensive assessment of health behaviors and cardiovascular disease (CVD) risk factors. Personalized TLC action plans addressed modifiable health behaviors for diet, exercise, stress management, and sleep. Participants attended a half-day interactive workshop and met face-to-face with certified health coaches four times over 6 months. Monthly telephonic coaching for 6 more months completed the intervention. Measured outcomes included adherence to behavioral prescriptions, anthropometrics, CVD-relevant laboratory tests, and for a subset of participants, carotid intima-media thickness (CIMT). Of 965 participants, 648 (67%) completed the program and were included in the analysis. Participants were of mean age 55.4 ± 12.5 years, 57% women, and racially diverse. Adherence to prescribed TLC was substantial: dietary behaviors at goal rose from 53% to 86%, exercise 44% to 66%, perceived stress 65% to 79%, and sleep quality 28% to 49%. For participants with abnormal anthropometrics at baseline, there were improvements in body mass index in 63%, waist circumference (men 71%, women 74%), systolic BP 69%, and diastolic BP 71%. For participants with abnormal laboratory values at baseline, there were improvements in total cholesterol in 74%, LDL-cholesterol 65%, triglycerides 86%, fasting glucose 72%, and insulin resistance 71%. Improvements were not driven by prescribed medications. CIMT improved or showed no change in 70% of those measured, associated with significant improvements in sleep quality and longer total sleep time. Longer trials incorporating controls and major adverse CVD events are warranted.
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Key Words
- ACEi, angiotensin converting enzyme inhibitor
- ARB, angiotensin receptor blocker
- BMI, body mass index in kg/m2
- BP, blood pressure
- Behavioral intervention
- CCB, calcium channel blocker
- CHP, Cardiovascular Health Program
- CIMT, carotid intima-media thickness
- CLIA, Clinical Laboratory Improvement Amendments
- Cardiovascular disease
- Cardiovascular risk
- DPP4, mdipeptidyl peptidase 4 inhibitor
- Dias BP, diastolic blood pressure in mm Hg
- ESS, Epworth Sleepiness Scale
- FBG, fasting blood glucose in mg/dL
- HOMA-IR, homeostatic model assessment for insulin resistance
- IPAQ, International Physical Activity Questionnaire
- IRB, institutional review board
- LDL, low density lipoprotein
- MACE, major adverse cardiovascular events
- NDRI, nicotine and dopamine reuptake inhibitor
- NP, nurse practitioner
- PSQI, Pittsburgh Sleep Quality Index
- PSS, Perceived Stress Scale
- Prevention
- RYP, Rate-Your-Plate
- SARI, serotonin antagonist and reuptake inhibitor
- SD, standard deviation
- SNRI, serotonin-norepinephrine reuptake inhibitor
- SPSS, Statistical Package for the Social Science
- SSRI, selective serotonin reuptake inhibitor
- Statin, HMG-CoA reductase inhibitor
- Sys BP, systolic blood pressure in mm Hg
- TCA, tricyclic antidepressant
- TLC, therapeutic lifestyle change
- Therapeutic lifestyle change
- Tot Chol, total cholesterol in mg/dL
- Trig, triglycerides in mg/dL
- WC, waist circumference in cm
- α Blocker, alpha blocker
- β blocker, beta blocker
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Affiliation(s)
- Arn Eliasson
- Cardiovascular Health Program Registry, Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817, United States.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - Mariam Kashani
- Cardiovascular Health Program Registry, Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817, United States
| | - Marina Vernalis
- Cardiovascular Health Program Registry, Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817, United States.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
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Helgeson SA, Enderby CY, Moss JE, Gass JM, Zeiger TK, Burger CD. Twelve-Year Survival in a Patient With Systemic Sclerosis-Associated Pulmonary Arterial Hypertension on Nifedipine Monotherapy. Mayo Clin Proc Innov Qual Outcomes 2019; 3:376-379. [PMID: 31485576 PMCID: PMC6713838 DOI: 10.1016/j.mayocpiqo.2019.06.002] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 11/29/2022] Open
Abstract
Pulmonary arterial hypertension is a progressive vascular disease with a high mortality rate without proper therapy. Identification of the appropriate treatment for each patient is critical in regard to adverse effects, health care costs, ease of treatment, and the potential for prognostication. Treatment strategies typically begin with acute vasoreactivity testing, which is performed during a right heart catherization. If positive, a calcium channel blocker may work; however, another pulmonary arterial hypertension-specific medication is necessary when testing is negative. Acute vasoreactivity testing is currently recommended to be performed only in certain subgroups of pulmonary arterial hypertension, but not when related to connective tissue disease. In this report, we describe a patient who had systemic sclerosis-related pulmonary arterial hypertension with a positive acute vasoreactivity test result. The patient was placed on calcium channel blocker monotherapy that has been well tolerated for 12 years, resulting in improved symptoms and exercise capacity. The long-term response to calcium channel blocker therapy in systemic sclerosis-associated pulmonary arterial hypertension has not been previously described. In addition, pulmonary artery pressures have been well controlled. The absence of genetic smooth muscle variants prevalent in vasoresponsive idiopathic pulmonary arterial hypertension is also unique.
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Key Words
- AVT, acute vasoreactivity testing
- CCB, calcium channel blocker
- CREST, calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia
- CTD, connective tissue disease
- PAH, pulmonary arterial hypertension
- PAOP, pulmonary arterial occlusion pressure
- PVR, pulmonary vascular resistance
- RHC, right heart catherization
- SSc, systemic sclerosis
- TTE, transthoracic echocardiogram
- mPAP, mean pulmonary arterial pressure
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Affiliation(s)
- Scott A Helgeson
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | - John E Moss
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Jennifer M Gass
- Department of Laboratory Genetics and Genomics, Greenwood Genetic Center, SC
| | - Tonya K Zeiger
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL
| | - Charles D Burger
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
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Amer T, Osman B, Johnstone A, Mariappan M, Gupta A, Brattis N, Jones G, Somani BK, Keeley FX, Aboumarzouk OM. Medical expulsive therapy for ureteric stones: Analysing the evidence from systematic reviews and meta-analysis of powered double-blinded randomised controlled trials. Arab J Urol 2017; 15:83-93. [PMID: 29071136 PMCID: PMC5653615 DOI: 10.1016/j.aju.2017.03.005] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 03/23/2017] [Accepted: 03/27/2017] [Indexed: 11/09/2022] Open
Abstract
Objective To conduct a systematic review and meta-analysis investigating the efficacy and safety of medical expulsive therapy (MET) in low risk of bias (RoB) randomised controlled trials (RCTs). Methods A Cochrane style systematic review was conducted on published literature from 1990 to 2016, to include low RoB and a power calculation. A pooled meta-analysis was conducted. Results The MET group included 1387 vs 1381 patients in the control group. The analysis reveals α-blockers increased stone expulsion rates (78% vs 74%) (P < 0.001), whilst calcium channel blockers (CCBs) had no effect compared to controls (79% vs 75%) (P = 0.38). In the subgroup analysis, α-blockers had a shorter time to stone expulsion vs the control group (P < 0.001). There were no significant differences in expulsion rates between the treatment groups and control group for stones <5 mm in size (P = 0.48), proximal or mid-ureteric stones (P = 0.63 and P = 0.22, respectively). However, α-blockers increased stone expulsion in stones >5 mm (P = 0.02), as well as distal ureteric stones (P < 0.001). The α-blocker group developed more side-effects (6.6% of patients; P < 0.001). The numbers needed to treat for α-blockers was one in 14, for stones >5 mm one in eight, and for distal stones one in 10. Conclusion The primary findings show a small overall benefit for α-blockers as MET for ureteric stones but no benefit with CCBs. α-blockers show a greater benefit for large (>5 mm) ureteric stones and those located in the distal ureter, but no benefit for smaller or more proximal stones. α-blockers are associated with a greater risk of side-effects compared to placebo or CCBs.
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Affiliation(s)
| | - Banan Osman
- Bristol Urological Institutes, North Bristol NHS Trust, Bristol, UK
| | | | | | | | - Nikolaos Brattis
- Bristol Urological Institutes, North Bristol NHS Trust, Bristol, UK
| | | | | | - Francis X Keeley
- Bristol Urological Institutes, North Bristol NHS Trust, Bristol, UK
| | - Omar M Aboumarzouk
- Glasgow Royal Infirmary, Glasgow, UK.,Bristol Urological Institutes, North Bristol NHS Trust, Bristol, UK.,Queen Elizabeth University Hospitals, Glasgow, UK.,Islamic Universities of Gaza, College of Medicine, Gaza, Palestine
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Polanco-Briceno S, Glass D, Caze A. Self-reported physician practices in pulmonary arterial hypertension: Diagnosis, assessment, and referral. Contemp Clin Trials Commun 2015; 2:54-60. [PMID: 29736446 PMCID: PMC5935852 DOI: 10.1016/j.conctc.2015.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 11/23/2015] [Revised: 12/21/2015] [Accepted: 12/23/2015] [Indexed: 11/16/2022] Open
Abstract
Background Numerous clinical trials have contributed to rapid advancements in the diagnosis and management of pulmonary arterial hypertension (PAH), yet patients often do not undergo right heart catheterization (RHC) with vasoreactivity testing and may receive a delayed or incorrect diagnosis. Efforts to improve standards of care include the designation of Pulmonary Hypertension Association (PHA)-Accredited PH Care Centers (PHCCs). This study evaluated current practices in the diagnosis and assessment of PAH. Methods A survey of 167 physicians who had ≥1 claim for PAH in the past 3 months was conducted. Results Of 167 respondents, 15% were affiliated with a PHCC, 40% had referred ≥1 patient with diagnosed PAH, and 79% had ≥1 patient referred to them by another physician who they then newly diagnosed with PAH. More than half (52%) reported having ≥1 patient who was previously misdiagnosed with PAH referred to them by another physician. RHC and vasoreactivity testing, respectively, were performed in 43% and 33% of patients with PAH who respondents referred to another physician, 86% and 67% of patients newly diagnosed by respondents, and 84% and 57% of patients who respondents considered accurately diagnosed prior to being referred to them. Respondents affiliated with a PHCC were more likely to try to refer to another physician affiliated with a PHCC, and to perform RHC and vasoreactivity testing. Conclusions Self-reported clinical practices often deviated from established guidelines. Future research should focus on both clinical efficacy and ways to encourage clinicians to bring their practices in line with well-supported, evidence-based recommendations.
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Affiliation(s)
| | - Daniel Glass
- Deerfield Institute, 780 Third Avenue, 37th floor, New York, NY, 10017, USA
| | - Alexis Caze
- Deerfield Institute, 780 Third Avenue, 37th floor, New York, NY, 10017, USA
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