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Kelsey MD, Kelsey AM. Diagnosing Coronary Artery Disease in the Patient Presenting with Stable Ischemic Heart Disease: The Role of Anatomic versus Functional Testing. Med Clin North Am 2024; 108:427-439. [PMID: 38548455 DOI: 10.1016/j.mcna.2023.11.002] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
There are unique advantages and disadvantages to functional versus anatomic testing in the work-up of patients who present with symptoms suggestive of obstructive coronary artery disease. Evaluation of these individuals starts with an assessment of pre-test probability, which guides subsequent testing decisions. The choice between anatomic and functional testing depends on this pre-test probability. In general, anatomic testing has particular utility among younger individuals and women; while functional testing can be helpful to rule-in ischemia and guide revascularization decisions. Ultimately, selection of the most appropriate test should be individualized to the patient and clinical scenario.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA.
| | - Anita M Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA. https://twitter.com/AnitaKelseyMD
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2
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Davis EF, Crousillat DR, Peteiro J, Lopez-Sendon J, Senior R, Shapiro MD, Pellikka PA, Lyubarova R, Alfakih K, Abdul-Nour K, Anthopolos R, Xu Y, Kunichoff DM, Fleg JL, Spertus JA, Hochman J, Maron D, Picard MH, Reynolds HR. Global Longitudinal Strain as Predictor of Inducible Ischemia in No Obstructive Coronary Artery Disease in the CIAO-ISCHEMIA Study. J Am Soc Echocardiogr 2024; 37:89-99. [PMID: 37722490 PMCID: PMC10842002 DOI: 10.1016/j.echo.2023.09.006] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/18/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Global longitudinal strain (GLS) is a sensitive marker for identifying subclinical myocardial dysfunction in obstructive coronary artery disease (CAD). Little is known about the relationship between GLS and ischemia in patients with myocardial ischemia and no obstructive CAD (INOCA). OBJECTIVES To investigate the relationship between resting GLS and ischemia on stress echocardiography (SE) in patients with INOCA. METHODS Left ventricular GLS was calculated offline on resting SE images at enrollment (n = 144) and 1-year follow-up (n = 120) in the CIAO-ISCHEMIA (Changes in Ischemia and Angina over One year in International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial screen failures with no obstructive CAD on computed tomography [CT] angiography) study, which enrolled participants with moderate or severe ischemia by local SE interpretation (≥3 segments with new or worsening wall motion abnormality and no obstructive (<50% stenosis) on coronary computed tomography angiography. RESULTS Global longitudinal strain values were normal in 83.3% at enrollment and 94.2% at follow-up. Global longitudinal strain values were not associated with a positive SE at enrollment (GLS = -21.5% positive SE vs GLS = -19.9% negative SE, P = .443) or follow-up (GLS = -23.2% positive SE vs GLS = -23.1% negative SE, P = .859). Significant change in GLS was not associated with positive SE in follow-up (P = .401). Regional strain was not associated with colocalizing ischemia at enrollment or follow-up. Changes in GLS and number of ischemic segments from enrollment to follow-up showed a modest but not clinically meaningful correlation (β = 0.41; 95% CI, 0.16, 0.67; P = .002). CONCLUSIONS In this cohort of INOCA patients, resting GLS values were largely normal and did not associate with the presence, severity, or location of stress-induced ischemia. These findings may suggest the absence of subclinical myocardial dysfunction detectable by echocardiographic strain analysis at rest in INOCA.
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Affiliation(s)
- Esther F Davis
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Victorian Heart Institute and Victorian Heart Hospital, Victoria, Australia
| | - Daniela R Crousillat
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Division of Cardiovascular Sciences, Department of Medicine, University of South Florida, Tampa, Florida; Department of Obstetrics and Gynecology, Tampa General-Heart and Vascular Institute, University of South Florida, Tampa, Florida
| | - Jesus Peteiro
- CHUAC, Universidad de A Coruña, CIBER-CV, A Coruna, Spain
| | | | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | - Michael D Shapiro
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | - Rebecca Anthopolos
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Yifan Xu
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Dennis M Kunichoff
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Jerome L Fleg
- National Institute of Health-National Heart Lung, and Blood Institute, Bethesda, Maryland
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Judith Hochman
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - David Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Michael H Picard
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Harmony R Reynolds
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York.
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3
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Zelesky T, Baertschi SW, Foti C, Allain LR, Hostyn S, Franca JR, Li Y, Marden S, Mohan S, Ultramari M, Huang Z, Adams N, Campbell JM, Jansen PJ, Kotoni D, Laue C. Pharmaceutical Forced Degradation ( Stress Testing) Endpoints: A Scientific Rationale and Industry Perspective. J Pharm Sci 2023; 112:2948-2964. [PMID: 37690775 DOI: 10.1016/j.xphs.2023.09.003] [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] [Received: 07/07/2023] [Revised: 09/01/2023] [Accepted: 09/01/2023] [Indexed: 09/12/2023]
Abstract
Forced degradation (i.e., stress testing) of small molecule drug substances and products is a critical part of the drug development process, providing insight into the intrinsic stability of a drug that is foundational to the development and validation of stability-indicating analytical methods. There is a lack of clarity in the scientific literature and regulatory guidance as to what constitutes an "appropriate" endpoint to a set of stress experiments. That is, there is no clear agreement regarding how to determine if a sample has been sufficiently stressed. Notably, it is unclear what represents a suitable justification for declaring a drug substance (DS) or drug product (DP) "stable" to a specific forced degradation condition. To address these concerns and to ensure all pharmaceutically-relevant, potential degradation pathways have been suitably evaluated, we introduce a two-endpoint classification designation supported by experimental data. These two endpoints are 1) a % total degradation target outcome (e.g., for "reactive" drugs) or, 2) a specified amount of stress, even in the absence of any degradation (e.g., for "stable" drugs). These recommended endpoints are based on a review of the scientific literature, regulatory guidance, and a forced degradation data set from ten global pharmaceutical companies. The experimental data set, derived from the Campbell et al. (2022) benchmarking study,1 provides justification for the recommendations. Herein we provide a single source reference for small molecule DS and DP forced degradation stress conditions and endpoint best practices to support regulatory submissions (e.g., marketing applications). Application of these forced degradation conditions and endpoints, as part of a well-designed, comprehensive and a sufficiently rigorous study plan that includes both the DS and DP, provides comprehensive coverage of pharmaceutically-relevant degradation and avoids unreasonably extreme stress conditions and drastic endpoint recommendations sometimes found in the literature.
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Affiliation(s)
- Todd Zelesky
- Analytical Research & Development, Pfizer Inc., Eastern Point Road, Groton, CT 06340, USA.
| | | | - Chris Foti
- Analytical Development and Operations, Gilead Sciences Inc., Foster City, California, USA.
| | | | - Steven Hostyn
- Predictive Analytics & Stability Sciences CoE, Janssen Pharmaceutica, Johnson & Johnson, Beerse, Belgium
| | | | - Yi Li
- Analytical Development and Operations, Gilead Sciences Inc., Foster City, California, USA
| | - Stacey Marden
- Advanced Drug Delivery, Pharmaceutical Sciences, R&D, AstraZeneca, Boston, MA, USA
| | - Shikhar Mohan
- Analytical Development and Operations, Gilead Sciences Inc., Foster City, California, USA
| | - Mariah Ultramari
- Spektra Soluções Científico-Regulatórias Ltda, São Paulo, Brazil
| | - Zongyun Huang
- Bristol-Myers Squibb Company, 1 Squibb Drive, New Brunswick, NJ 08901, USA
| | - Neal Adams
- Pfizer, Scientific and Laboratory Services - Analytical Sciences, Pfizer Inc., 7000 Portage Road, Kalamazoo, MI 49001, USA
| | - John M Campbell
- Analytical Development, GSK, Upper Providence, PA 19426, USA
| | - Patrick J Jansen
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN 46285, USA
| | - Dorina Kotoni
- Chemical & Analytical Development, Novartis Pharma AG, Basel, Switzerland
| | - Christian Laue
- Chemical & Pharmaceutical Development, Merck Healthcare KGaA, Darmstadt, Germany
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Inkinen SI, Hippeläinen E, Uusitalo V. Adenosine-induced splenic switch-off on [ 15O]H 2O PET perfusion for the assessment of vascular vasodilatation. EJNMMI Res 2023; 13:96. [PMID: 37943363 PMCID: PMC10635971 DOI: 10.1186/s13550-023-01045-7] [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] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Splenic switch-off (SSO) is a marker of adequate adenosine-induced vasodilatation on cardiac magnetic resonance perfusion imaging. We evaluate the feasibility of quantitative assessment of SSO in myocardial positron emission tomography (PET) perfusion imaging using [15O]H2O. METHODS Thirty patients underwent [15O]H2O PET perfusion with adenosine stress. Time-activity curves, as averaged standardized uptake values (SUVavg), were extracted from dynamic PET for spleen and liver. Maximum SUVavg, stress and rest spleen-to-liver ratio (SLR), and the splenic activity concentration ratio (SAR) were computed. Optimal cut-off values for SSO assessment were estimated from receiver operating characteristics (ROC) curve for maximum SUVavg and SLR. Also, differences between coronary artery disease, myocardial ischemia, beta-blockers, and diabetes were assessed. Data are presented as median [interquartile range]. RESULTS In concordance with the SSO phenomenon, both the spleen maximum SUVavg and SLR were lower in adenosine stress when compared to rest perfusion (8.1 [6.5, 9.2] versus 16.4 [13.4, 19.0], p < 0.001) and (0.81 [0.63, 1.08] versus 1.86 [1.73, 2.06], p < 0.001), respectively. During adenosine stress, the SSO effect was most prominent 40-160 s after radiotracer injection. Cut-off values of 12.6 and 1.57 for maximum SUVavg and SLR, respectively, were found based on ROC analysis. No differences in SAR, SLRRest, or SLRStress were observed in patients with coronary artery disease, myocardial ischemia, or diabetes. CONCLUSIONS SSO can be quantified from [15O]H2O PET perfusion and used as a marker for adequate adenosine-induced vasodilatation response. In contrary to other PET perfusion tracers, adenosine-induced SSO is time dependent with [15O]H2O.
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Affiliation(s)
- Satu Irene Inkinen
- HUS Diagnostic Center, Clinical Physiology and Nuclear Medicine, Helsinki University and Helsinki University Hospital, Helsinki, Finland.
| | - Eero Hippeläinen
- HUS Diagnostic Center, Clinical Physiology and Nuclear Medicine, Helsinki University and Helsinki University Hospital, Helsinki, Finland
- Department of Physics, University of Helsinki, Helsinki, Finland
| | - Valtteri Uusitalo
- HUS Diagnostic Center, Clinical Physiology and Nuclear Medicine, Helsinki University and Helsinki University Hospital, Helsinki, Finland
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Pezel T, Unterseeh T, Hovasse T, Sanguineti F, Garot P, Champagne S, Toupin S, Ah-Sing T, Faradji A, Nicol M, Hamzi L, Dillinger JG, Henry P, Bousson V, Garot J. Safety and incremental prognostic value of stress cardiovascular magnetic resonance in patients with known chronic kidney disease. J Cardiovasc Magn Reson 2023; 25:29. [PMID: 37308923 PMCID: PMC10259036 DOI: 10.1186/s12968-023-00939-8] [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] [Received: 11/26/2022] [Accepted: 05/15/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is the main cause of mortality in patients with chronic kidney disease (CKD). Although several studies have demonstrated the consistently high prognostic value of stress cardiovascular magnetic resonance (CMR), its prognostic value in patients with CKD is not well established. We aimed to assess the safety and the incremental prognostic value of vasodilator stress perfusion CMR in consecutive symptomatic patients with known CKD. METHODS Between 2008 and 2021, we conducted a retrospective dual center study with all consecutive symptomatic patients with known stage 3 CKD, defined by estimated glomerular filtration rate (eGFR) between 30 and 60 ml/min/1.73 m2, referred for vasodilator stress CMR. All patients with eGFR < 30 ml/min/1.73 m2 (n = 62) were excluded due the risk of nephrogenic systemic fibrosis. All patients were followed for the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death or recurrent nonfatal myocardial infarction (MI). Cox regression analysis was used to determine the prognostic value of stress CMR parameters. RESULTS Of 825 patients with known CKD (71.4 ± 8.8 years, 70% men), 769 (93%) completed the CMR protocol. Follow-up was available in 702 (91%) (median follow-up 6.4 (4.0-8.2) years). Stress CMR was well tolerated without occurrence of death or severe adverse event related to the injection of gadolinium or cases of nephrogenic systemic fibrosis. The presence of inducible ischemia was associated with the occurrence of MACE (hazard ratio [HR] 12.50; 95% confidence interval [CI] 7.50-20.8; p < 0.001). In multivariable analysis, ischemia and late gadolinium enhancement were independent predictors of MACE (HR 15.5; 95% CI 7.72 to 30.9; and HR 4.67 [95% CI 2.83-7.68]; respectively, both p < 0.001). After adjustment, stress CMR findings showed the best improvement in model discrimination and reclassification above traditional risk factors (C-statistic improvement: 0.13; NRI = 0.477; IDI = 0.049). CONCLUSIONS In patients with known stage 3 CKD, stress CMR is safe and its findings have an incremental prognostic value to predict MACE over traditional risk factors.
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Affiliation(s)
- Théo Pezel
- Université de Paris Cité, Service de Cardiologie, Hôpital Lariboisière-APHP, Inserm UMRS 942, 75010, Paris, France
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Thierry Unterseeh
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Thomas Hovasse
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Francesca Sanguineti
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Philippe Garot
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Stéphane Champagne
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Solenn Toupin
- Siemens Healthcare France, 93200, Saint-Denis, France
| | - Tania Ah-Sing
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Alyssa Faradji
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Martin Nicol
- Université de Paris Cité, Service de Cardiologie, Hôpital Lariboisière-APHP, Inserm UMRS 942, 75010, Paris, France
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Lounis Hamzi
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Jean Guillaume Dillinger
- Université de Paris Cité, Service de Cardiologie, Hôpital Lariboisière-APHP, Inserm UMRS 942, 75010, Paris, France
| | - Patrick Henry
- Université de Paris Cité, Service de Cardiologie, Hôpital Lariboisière-APHP, Inserm UMRS 942, 75010, Paris, France
| | - Valérie Bousson
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Jérôme Garot
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
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Picano E, Ciampi Q, Arbucci R, Cortigiani L, Zagatina A, Celutkiene J, Bartolacelli Y, Kane GC, Lowenstein J, Pellikka P. Stress Echo 2030: the new ABCDE protocol defining the future of cardiac imaging. Eur Heart J Suppl 2023; 25:C63-C67. [PMID: 37125276 PMCID: PMC10132595 DOI: 10.1093/eurheartjsupp/suad008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Functional testing with stress echocardiography is based on the detection of regional wall motion abnormality with two-dimensional echocardiography and is embedded in clinical guidelines. Yet, it under-uses the unique versatility of the technique, ideally suited to describe the different functional abnormalities underlying the same wall motion response during stress. Five parameters converge conceptually and methodologically in the state-of-the-art ABCDE protocol, assessing multiple vulnerabilities of the ischemic patient. The five steps of the ABCDE protocol are (1) step A: regional wall motion; (2) step B: B-lines by lung ultrasound assessing extravascular lung water; (3) step C: left ventricular contractile reserve by volumetric two-dimensional echocardiography; (4) step D: coronary flow velocity reserve in mid-distal left anterior descending coronary with pulsed-wave Doppler; and (5) step E: assessment of heart rate reserve with a one-lead electrocardiogram. ABCDE stress echo offers insight into five functional reserves: epicardial flow (A); diastolic (B), contractile (C), coronary microcirculatory (D), and chronotropic reserve (E). The new format is more comprehensive and allows better functional characterization, risk stratification, and personalized tailoring of therapy. ABCDE protocol is an 'ecumenic' and 'omnivorous' functional test, suitable for all stresses and all patients also beyond coronary artery disease. It fits the need for sustainability of the current era in healthcare, since it requires universally available technology, and is low-cost, radiation-free, and nearly carbon-neutral.
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Affiliation(s)
- Eugenio Picano
- CNR, Istituto Fisiologia Clinica—Dipartimento di Biomedicina—Consiglio Nazionale delle Ricerche, CNR Research Campus, Via Moruzzi 1, Building C- Room 130, Pisa 56124, Italy
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, Viale Principe di Napoli 14A, Benevento 82100, Italy
| | - Rosina Arbucci
- Cardiodiagnosticos, Investigaciones Medicas Center, Pichincha 69, Buenos Aires C1082, Argentina
| | - Lauro Cortigiani
- Cardiology Department, San Luca Hospital, Via Guglielmo Lippi Francesconi, Località San Filippo, Lucca 55100, Italy
| | - Angela Zagatina
- Cardiology Department, Saint Petersburg State Pediatric Medical University, Litovkaya St 2, Saint Petersburg 194100, Russian Federation
| | - Jelena Celutkiene
- Centre of Cardiology and Angiology, Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Clinical Medicine, Vilnius LT-03101, Lithuania
| | - Ylenia Bartolacelli
- Paediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna 40138, Italy
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Jorge Lowenstein
- Cardiodiagnosticos, Investigaciones Medicas Center, Pichincha 69, Buenos Aires C1082, Argentina
| | - Patricia Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Rozanski A, Sakul S, Narula J, Uretsky S, Lavie CJ, Berman D. Assessment of lifestyle-related risk factors enhances the effectiveness of cardiac stress testing. Prog Cardiovasc Dis 2023; 77:95-106. [PMID: 36931544 DOI: 10.1016/j.pcad.2023.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
Cardiac stress tests have been widely utilized since the 1960s for the diagnostic and prognostic assessment of patients with suspected coronary artery disease (CAD). Clinical risk is primarily based on assessing the presence and magnitude of inducible myocardial ischemia. However, the primary factors driving mortality risk have changed over recent decades. Factors such as typical angina and inducible ischemia have decreased, whereas the percentage of patients with diabetes, obesity and hypertension have increased. There has also been a marked temporal increase in the percentage of patients who require pharmacologic testing due to inability to perform treadmill exercise at the time of cardiac stress testing and this need has emerged as the most potent predictor of mortality risk in contemporary stress test populations. However, the long-term clinical risk posed by the inability to perform exercise and concomitant CAD risk factors are rarely reflected in the assessment of patients' prognostic risk in cardiac stress test reports. In this review, we suggest that the clinical utility of present-day cardiac stress testing can be improved by developing a more comprehensive assessment that integrates and reports all factors which modulate patients' long-term clinical risk following stress testing. This should include assessment of patients' CAD risk factors, physical activity habits and mobility risks, identification of the reasons why patients could not exercise at the time of cardiac stress testing. In addition, the assessment of four core non-aerobic functional parameters should be considered among patients who cannot exercise: assessment of gait speed, handgrip strength, lower extremity strength, and standing balance.
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Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Sakul Sakul
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Jagat Narula
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Seth Uretsky
- Morristown Medical Center, Morristown, NJ, United States of America
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the UQ School of Medicine, New Orleans, LA, United States of America
| | - Daniel Berman
- Departments of Imaging and Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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8
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Guo K, He X, Zhao H, Ma C. Characterisation of degradation products of tegoprazan by LC-MS and GC-MS. J Pharm Biomed Anal 2023; 228:115323. [PMID: 36921447 DOI: 10.1016/j.jpba.2023.115323] [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] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/06/2023]
Abstract
Tegoprazan is a novel orally active potassium-competitive acid blocker (P-CAB), capable of binding to the K+ binding site of H+/K+-ATPase in a reversible way to inhibit gastric acid secretion. Tegoprazan has been approved for treating acid-related diseases. In this study, stress testings of tegoprazan were performed under various conditions, including hydrolysis (acidic, alkaline, and neutral), oxidation, photolysis, and thermal stress. Tegoprazan showed instability in acidic, alkaline, and oxidative conditions. Eight degradation products (DPs) were identified. The DPs were characterized by LC-HRMS, LC-MSn, or GC-Q-TOF-MS. Meanwhile, DP-1, DP-2 and DP-3 were successfully synthesized and confirmed by NMR. The degradation pathway of tegoprazan was summarized. To the best of our knowledge, this is the first study on the forced degradation of tegoprazan.
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Affiliation(s)
- Kaijing Guo
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100050, China
| | - Xiao He
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100050, China
| | - Hongyi Zhao
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100050, China
| | - Chen Ma
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100050, China.
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9
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Pérez-Robles R, Salmerón-García A, Hermosilla J, Torrente-López A, Clemente-Bautista S, Jiménez-Lozano I, Cabañas-Poy MJ, Cabeza J, Navas N. Comprehensive physicochemical characterization of a peptide-based medicine: Teduglutide (Revestive®) structural description and stress testing. Eur J Pharm Biopharm 2023; 184:103-115. [PMID: 36669672 DOI: 10.1016/j.ejpb.2023.01.001] [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] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/29/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023]
Abstract
Teduglutide (Revestive®) is a glucagon-like peptide-2 analogue used for the treatment of short bowel syndrome, a rare life-threatening condition in which the amount of functional gut is too short to enable proper absorption of nutrients and fluids. During handling prior to administration to the patient in hospital, it is possible that peptide-based medicines may be exposed to environmental stress conditions that could affect their quality. It is therefore essential to carry out stress testing studies to evaluate how such medicines respond to these stresses. For this reason, in this paper we present a strategy for a comprehensive analytical characterization of a peptide and a stress testing study in which it was subjected to various stress conditions: heating at 40 °C and 60 °C, light exposure and shaking. Several complementary analytical techniques were used throughout this study: Far UV circular dichroism, intrinsic protein fluorescence spectroscopy, dynamic light scattering, size-exclusion chromatography and intact and peptide mapping reverse-phase chromatography coupled to mass spectrometry. To the best of our knowledge, this is the first study to offer an in-depth description of the chemical structure of teduglutide peptide and its physicochemical characteristics after stress stimuli were applied to the reconstituted medicine Revestive®.
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Affiliation(s)
- Raquel Pérez-Robles
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain; Fundación para la Investigación Biosanitaria de Andalucía Oriental-Alejandro Otero, Granada, Spain
| | - Antonio Salmerón-García
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Clinical Pharmacy, San Cecilio University Hospital, Granada, Spain
| | - Jesus Hermosilla
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain
| | - Anabel Torrente-López
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain
| | | | - Inés Jiménez-Lozano
- Maternal and Child Pharmacy Service, Vall d'Hebron Hospital, Pharmacy, Barcelona, Spain
| | | | - Jose Cabeza
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Clinical Pharmacy, San Cecilio University Hospital, Granada, Spain
| | - Natalia Navas
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain.
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10
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Sorrell VL, Lindner JR, Pellikka PA, Kirkpatrick JN, Muraru D. Recognized and Unrecognized Value of Echocardiography in Guideline and Consensus Documents Regarding Patients With Chest Pain. J Am Soc Echocardiogr 2023; 36:146-153. [PMID: 36375734 DOI: 10.1016/j.echo.2022.10.024] [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: 06/25/2022] [Revised: 10/21/2022] [Accepted: 10/26/2022] [Indexed: 11/13/2022]
Abstract
Guideline and consensus documents have recently been published on the important topic of the noninvasive evaluation of patients presenting with chest pain (CP) or patients with known acute or chronic coronary syndromes. Authors for these documents have included members representing multispecialty imaging societies, yet the process of generating consensus and the need to produce concise written documents have led to a situation where the particular advantages of echocardiography are overlooked. Broad guidelines such as these can be helpful when it comes to "when to do" noninvasive cardiac testing, but they do not pretend to offer nuances on "how to do" noninvasive cardiac testing. This report details the particular value of echocardiography and potential explanations for its understated role in recent guidelines. This report is categorized into the following sections: (1) impact of the level of evidence on guideline creation; (2) versatility of echocardiography in the assessment of CP and the inimitable role for echo Doppler echocardiography in the assessment of dyspnea; (3) value of point-of-care ultrasound in assessing CP and dyspnea; and (4) the future role of echocardiography in ischemic heart disease.
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Affiliation(s)
- Vincent L Sorrell
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky.
| | - Jonathan R Lindner
- Vice-chief for Research in the Cardiology Division, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | | | - James N Kirkpatrick
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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11
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Divakaran S, Lopez DM, Parks SM, Hainer J, Ng AK, Blankstein R, Di Carli MF, Nohria A. Functional testing, coronary artery calcifications, and outcomes in Hodgkin lymphoma survivors treated with chest radiation. Cardiooncology 2023; 9:5. [PMID: 36670480 PMCID: PMC9854101 DOI: 10.1186/s40959-023-00157-2] [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] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 01/09/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Consensus guidelines recommend periodic screening for coronary artery disease (CAD) in Hodgkin lymphoma (HL) survivors treated with radiation therapy (RT) to the chest. However, the prognostic utility of screening strategies in this population remains unclear. We evaluated the association between functional testing, coronary artery calcifications (CAC), and guideline-based risk assessment and major adverse cardiovascular events (MACE) in HL survivors treated with RT. METHODS We retrospectively studied HL survivors treated with RT who underwent functional testing between 2003 and 2020 and chest computed tomography (CT) within 12 months of each other at our center. CAC was assessed semi-quantitatively from CT images. Cardiovascular risk was estimated using the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Diagnostic test characteristics were calculated using major adverse cardiac events (MACE) during follow-up as the gold standard. RESULTS The study included 159 patients (median age at functional testing 48 years, median age at HL diagnosis 27 years, 62.9% female). Abnormal functional testing had the highest specificity (94.2% (95% CI 88.4%-97.6%)) and positive likelihood ratio (4.55 (95% CI 1.86-11.13)) while CAC had the highest sensitivity (63.2% (95% CI 46.0%-78.2%)) and lowest negative likelihood ratio (0.52 (95% CI 0.34-0.80)). Specificity for ACC/AHA risk assessment was also high (88.5% (95% CI 81.1%-93.7%)). Over 3.3 years of follow-up, abnormal functional testing (adjusted subdistribution hazard ratio (SHR) 5.10, 95% CI 2.41 - 10.78, p < 0.001) and CAC (adjusted SHR 3.58, 95% CI 1.35 - 9.47, p = 0.010) were both significantly associated with MACE. CONCLUSIONS In HL survivors treated with RT, both abnormal functional testing and ACC/AHA risk assessment had high specificity for subsequent MACE, but CAC had higher sensitivity. Further research is needed to inform CAD screening and primary prevention strategies in this population.
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Affiliation(s)
- Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Brigham & Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Diana M Lopez
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Brigham & Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Sean M Parks
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrea K Ng
- Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Brigham & Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Brigham & Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Anju Nohria
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Brigham & Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
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12
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Pezel T, Bonnet G, Kinnel M, Asselin A, Hovasse T, Unterseeh T, Champagne S, Sanguineti F, Toupin S, Garot P, Garot J. Clustering of patients with inconclusive non-invasive stress testing referred for vasodilator stress cardiovascular magnetic resonance. Arch Cardiovasc Dis 2022; 115:627-636. [PMID: 36376207 DOI: 10.1016/j.acvd.2022.08.004] [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: 04/18/2022] [Revised: 06/12/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Inconclusive non-invasive stress testing is associated with impaired outcome. This population is very heterogeneous, and its characteristics are not well depicted by conventional methods. AIMS To identify patient subgroups by phenotypic unsupervised clustering, integrating clinical and cardiovascular magnetic resonance data to unveil pathophysiological differences between subgroups of patients with inconclusive stress tests. METHODS Between 2008 and 2020, consecutive patients with a first inconclusive non-invasive stress test referred for stress cardiovascular magnetic resonance were followed for the occurrence of major adverse cardiovascular events (defined as cardiovascular death or myocardial infarction). A cluster analysis was performed on clinical and cardiovascular magnetic resonance variables. RESULTS Of 1402 patients (67% male; mean age 70±11years) who completed the follow-up (median 6.5years, interquartile range 5.6-7.5years), 197 experienced major adverse cardiovascular events (14.1%). Three distinct phenogroups were identified based upon unsupervised hierarchical clustering of principal components: phenogroup 1=history of percutaneous coronary intervention with viable myocardial infarction and preserved left ventricular ejection fraction; phenogroup 2=atrial fibrillation with preserved left ventricular ejection fraction; and phenogroup 3=coronary artery bypass graft with non-viable myocardial scar and reduced left ventricular ejection fraction. Using survival analysis, the occurrence of major adverse cardiovascular events (P=0.007), cardiovascular mortality (P=0.002) and all-cause mortality (P<0.001) differed among the three phenogroups. Phenogroup 3 presented the worse prognosis. In each phenogroup, ischaemia was associated with major adverse cardiovascular events (phenogroup 1: hazard ratio 2.79, 95% confidence interval 1.61-4.84; phenogroup 2: hazard ratio 2.59, 95% confidence interval 1.69-3.97; phenogroup 3: hazard ratio 3.16, 95% confidence interval 1.82-5.49; all P<0.001). CONCLUSIONS Cluster analysis of clinical and cardiovascular magnetic resonance variables identified three phenogroups of patients with inconclusive stress testing, with distinct prognostic profiles.
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Affiliation(s)
- Théo Pezel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France; Department of Cardiology, Lariboisière Hospital, AP-HP, Inserm UMRS 942, University of Paris, 75010 Paris, France
| | - Guillaume Bonnet
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
| | - Marine Kinnel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | | | - Thomas Hovasse
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | - Thierry Unterseeh
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | - Stéphane Champagne
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | - Francesca Sanguineti
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | - Solenn Toupin
- Scientific Partnerships Division, Siemens Healthcare France, 93200 Saint-Denis, France
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | - Jérôme Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France.
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13
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Orlowska M, Bézy S, Ramalli A, Voigt JU, D'hooge J. High-Frame-Rate Speckle Tracking for Echocardiographic Stress Testing. Ultrasound Med Biol 2022; 48:1644-1651. [PMID: 35637027 DOI: 10.1016/j.ultrasmedbio.2022.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/21/2022] [Accepted: 04/20/2022] [Indexed: 06/15/2023]
Abstract
Stress echocardiography helps to diagnose cardiac diseases that cannot easily be detected or do not even manifest at rest. In clinical practice, assessment of the stress test is usually performed visually and, therefore, in a qualitative and subjective way. Although speckle tracking echocardiography (STE) has been proposed for the quantification of function during stress, its time resolution is inadequate at high heart rates. Recently, high-frame-rate (HFR) imaging approaches have been proposed together with dedicated STE algorithms capable of handling small interframe displacements. The aim of this study was to determine if HFR STE is effective in assessing strain and strain rate parameters during echocardiographic stress testing. Specifically, stress echocardiography, at four different workload intensities, was performed in 25 healthy volunteers. At each stress level, HFR images from the apical four-chamber view were recorded using the ULA-OP 256 experimental scanner. Then, the myocardium was tracked with HFR STE, and strain and strain rate biomarkers were extracted to further analyze systolic and diastolic (early and late) peaks, as well as a short-lived isovolumic relaxation peak during stress testing. The global systolic strain response was monophasic, revealing a significant (p < 0.001) increase at low stress but then reaching a plateau. In contrast, all strain rate indices linearly increased (p < 0.001) with increasing stress level. These findings are in line with those reported using tissue Doppler imaging and, thus, indicate that HFR STE can be a useful tool in assessing cardiac function during stress echocardiography.
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Affiliation(s)
- Marta Orlowska
- Laboratory of Cardiovascular Imaging and Dynamics, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - Stéphanie Bézy
- Laboratory of Cardiovascular Imaging and Dynamics, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Alessandro Ramalli
- Department of Information Engineering, University of Florence, Florence, Italy
| | - Jens-Uwe Voigt
- Laboratory of Cardiovascular Imaging and Dynamics, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Jan D'hooge
- Laboratory of Cardiovascular Imaging and Dynamics, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
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14
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Huo Y, Xu K, Lu Y, Ma L, Zhou C, Hang T, Song M. Characterization of structurally related peptide impurities using HPLC-QTOF-MS/MS: application to Cbf-14, a novel antimicrobial peptide. Anal Bioanal Chem 2022. [PMID: 35840670 DOI: 10.1007/s00216-022-04205-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/14/2022] [Accepted: 06/28/2022] [Indexed: 11/01/2022]
Abstract
Cbf-14 (RLLRKFFRKLKKSV), a designed antimicrobial peptide derived from the cathelicidin family, is effective against drug-resistant bacteria. Structurally related peptide impurities in peptide medicines probably have side effects or even toxicity, thus impurity profiling research during the entire production process is indispensable. In this study, a simple liquid chromatography-high-resolution mass spectrometry (LC-HRMS) method using a quadrupole time-of-flight (Q-TOF) mass spectrometer was developed for separation, identification, and characterization of structurally related peptide impurities in Cbf-14. A total of one process-related impurity and thirty-two degradation products were identified, and seven of them have been synthesized and confirmed. These impurities have not been declared in custom synthetic peptides. The degradation products were divided into five categories: fifteen Cbf-14 hydrolysates, five Cbf-14 isomers, four acetyl-Cbf-14 isomers, two aldimine derivatives, and six oxidized impurities. Combined with the peptide synthesis and the stress-testing studies, the origins and the formation mechanisms of these impurities were elucidated, which provides a unique insight for the follow-up quality study of Cbf-14 and other peptide products.
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15
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Smith DL, Graham EL, Douglas JA, Jack K, Conner MJ, Arena R, Chaudhry S. Subclinical Cardiac Dysfunction is Associated with Reduced Cardiorespiratory Fitness and Cardiometabolic Risk Factors in Firefighters. Am J Med 2022; 135:752-760.e3. [PMID: 35134370 DOI: 10.1016/j.amjmed.2021.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 07/20/2021] [Revised: 12/08/2021] [Accepted: 12/08/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Past studies have documented the ability of cardiopulmonary exercise testing to detect cardiac dysfunction in symptomatic patients with coronary artery disease. Firefighters are at high risk for work-related cardiac events. This observational study investigated the association of subclinical cardiac dysfunction detected by cardiopulmonary exercise testing with modifiable cardiometabolic risk factors in asymptomatic firefighters. METHODS As part of mandatory firefighter medical evaluations, study subjects were assessed at 2 occupational health clinics serving 21 different fire departments. Mixed effects logistic regression analyses were used to estimate odds ratios (ORs) and account for clustering by fire department. RESULTS Of the 967 male firefighters (ages 20-60 years; 84% non-Hispanic white; 14% on cardiovascular medications), nearly two-thirds (63%) had cardiac dysfunction despite having normal predicted cardiorespiratory fitness (median peak VO2 = 102%). In unadjusted analyses, cardiac dysfunction was significantly associated with advanced age, obesity, diastolic hypertension, high triglycerides, low high-density lipoprotein (HDL) cholesterol, and reduced cardiorespiratory fitness (all P values < .05). After adjusting for age and ethnicity, the odds of having cardiac dysfunction were approximately one-third higher among firefighters with obesity and diastolic hypertension (OR = 1.39, 95% confidence interval [CI] = 1.03-1.87 and OR = 1.36, 95% CI = 1.03-1.80) and more than 5 times higher among firefighters with reduced cardiorespiratory fitness (OR = 5.41, 95% CI = 3.29-8.90). CONCLUSION Subclinical cardiac dysfunction detected by cardiopulmonary exercise testing is a common finding in career firefighters and is associated with substantially reduced cardiorespiratory fitness and cardiometabolic risk factors. These individuals should be targeted for aggressive risk factor modification to increase cardiorespiratory fitness as part of an outpatient prevention strategy to improve health and safety.
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Affiliation(s)
- Denise L Smith
- First Responder Health and Safety Lab, Department of Health and Human Physiological Sciences, Skidmore College, Saratoga Springs, NY
| | - Elliot L Graham
- First Responder Health and Safety Lab, Department of Health and Human Physiological Sciences, Skidmore College, Saratoga Springs, NY
| | - Julie A Douglas
- Department of Mathematics and Statistics, Skidmore College, Saratoga Springs, NY; Department of Human Genetics, University of Michigan, Ann Arbor
| | | | | | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, Chicago; Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, Ill
| | - Sundeep Chaudhry
- Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, Ill; Research and Development, MET-TEST, Atlanta, Ga.
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16
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Rozanski A, Gransar H, Hayes SW, Friedman JD, Thomson L, Berman DS. Mortality risk among patients undergoing exercise versus pharmacologic myocardial perfusion imaging: A propensity-based comparison. J Nucl Cardiol 2022; 29:840-852. [PMID: 33047282 DOI: 10.1007/s12350-020-02294-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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] [Received: 05/03/2020] [Accepted: 06/22/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND The increased risk associated with pharmacologic versus exercise testing is obscured by the higher prevalence of clinical risk factors among pharmacologic patients. Thus, we assessed comparative mortality in a large risk factor-matched group of exercise versus pharmacologic patients undergoing stress/rest SPECT myocardial perfusion imaging (MPI). METHODS 39,179 patients undergoing stress/rest SPECT-MPI were followed for 13.3 ± 5.0 years for all-cause mortality (ACM). We applied propensity-matching to create pharmacologic and exercise groups with similar risk profiles. RESULTS In comparison to exercise patients, pharmacologic patients had an increased risk-adjusted hazard ratio for ACM for each level of ischemia: increased by 3.8-fold (95%CI 3.5-4.1) among nonischemic patients, 2.5-fold (95%CI 2.0-3.2) among mildly ischemic patients, and 2.6-fold (95%CI 2.1-3.3) among moderate/severe ischemic patients. Similar findings were observed among a propensity-matched cohort of 10,113 exercise and 10,113 pharmacologic patients as well as in an additional cohort that also excluded patients with noncardiac co-morbidities. CONCLUSIONS Patients requiring pharmacologic stress testing manifest substantially heightened clinical risk at each level of myocardial ischemia and even when myocardial ischemia is absent. These findings suggest the need to study the pathophysiological drivers of increased risk in association with pharmacologic testing and to convey this risk in clinical reports.
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Affiliation(s)
- Alan Rozanski
- The Department of Cardiology, Mount Sinai Morningside Hospital and Mount Sinai Heart, 1111 Amsterdam Avenue, New York, 10025, USA.
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Heidi Gransar
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Sean W Hayes
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - John D Friedman
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Louise Thomson
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Daniel S Berman
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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17
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Vymyslický F, Křížek T, Kozlík P, Kubíčková A, Heřt J, Bartosińska E. Alternative method for canagliflozin oxidation analysis using an electrochemical flow cell - Comparative study. J Pharm Biomed Anal 2022; 207:114341. [PMID: 34474952 DOI: 10.1016/j.jpba.2021.114341] [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] [Received: 05/07/2021] [Revised: 07/26/2021] [Accepted: 08/22/2021] [Indexed: 11/18/2022]
Abstract
This paper highlights the potential of electrochemical flow cells for oxidative-stress testing of active pharmaceutical ingredients using canagliflozin as a model substance. Based on design of experiments, we developed our method through a reduced combinatorial design, optimizing the following independent variables: cell size, electrolyte flow rate, electrolyte concentration, and electrolyte pH. Using ammonium phosphate buffer with methanol in a 50/50 vol ratio as a working electrolyte, we electrochemically oxidized samples and analyzed them by high-performance liquid chromatography, considering the following dependent variables: peak area of each impurity, peak area of canagliflozin, and the percentage of the corresponding peak areas. Our results showed that the most significant independent variables were electrolyte pH and flow rate. By data optimization, we determined the most suitable conditions for electrochemical oxidation of canagliflozin, namely 50 µm cell size, 300 mM electrolyte concentration, 0.1 mL/h electrolyte flow rate, and electrolyte pH = 4. The repeatability of the method, expressed as the relative standard deviation of the canagliflozin peak area, measured in ten separately oxidized samples, was 1.64%. For comparison purposes, we performed a degradation experiment using hydrogen peroxide, identifying five identical impurities in both cases, as confirmed by mass spectrometry. The degradation products formed when using the chemical method after 1, 3, and 7 days totaled 0.09%, 0.75%, and 3.75%, respectively, and the degradation products formed when using the electrochemical method after 3 h totaled 3.11%. Oxidation with hydrogen peroxide required 7 days, whereas electrochemical oxidation was completed in 3 h. Overall, the electrochemical method significantly saves time and reduces the consumption of active ingredients and solvents thanks to the miniaturized size of the electrochemical cell, thereby minimizing the costs of forced degradation studies.
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Affiliation(s)
- Filip Vymyslický
- Charles University, Faculty of Science, Department of Analytical Chemistry, Hlavova 8/2030, 128 43 Prague 2, Czech Republic
| | - Tomáš Křížek
- Charles University, Faculty of Science, Department of Analytical Chemistry, Hlavova 8/2030, 128 43 Prague 2, Czech Republic.
| | - Petr Kozlík
- Charles University, Faculty of Science, Department of Analytical Chemistry, Hlavova 8/2030, 128 43 Prague 2, Czech Republic
| | - Anna Kubíčková
- Charles University, Faculty of Science, Department of Analytical Chemistry, Hlavova 8/2030, 128 43 Prague 2, Czech Republic
| | - Jakub Heřt
- Zentiva Group, a.s., U Kabelovny 130, 102 37 Prague 10, Czech Republic
| | - Ewa Bartosińska
- Zentiva Group, a.s., U Kabelovny 130, 102 37 Prague 10, Czech Republic
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18
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Khan A, Engineer R, Wang S, Jaber WA, Menon V, Cremer PC. Initial experience regarding the safety and yield of rest-stress myocardial perfusion imaging in emergency department patients with mildly abnormal high-sensitivity cardiac troponins. J Nucl Cardiol 2021; 28:2941-2948. [PMID: 32557148 DOI: 10.1007/s12350-020-02145-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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] [Received: 11/12/2019] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND With high-sensitivity troponin testing, approximately a third of patients presenting to emergency departments (EDs) with suspected acute coronary syndromes will have mildly abnormal values. However, data regarding rest-stress myocardial perfusion imaging (MPI) in these patients are limited. We hypothesize that stress testing is safe and that the yield for detecting myocardial ischemia is associated with risk stratification by the HEART score. METHODS AND RESULTS We conducted a retrospective cohort study of consecutive patients referred for rest-stress MPI with mildly abnormal high-sensitivity troponin T (hs-cTn) values. Outcomes were adverse events related to stress MPI, defined as myocardial infarction or ventricular tachyarrhythmia, and the presence of ischemia, defined as a reversible perfusion defect. Among 213 patients, the median age was 67, most were male (61.5%, n = 131), and prior CAD was common (53.5%, n = 114). Myocardial ischemia was present in 13.6% (n = 29), and there were no adverse events attributable to stress MPI. A higher HEART score was associated with myocardial ischemia (Odds Ratio [OR] 1.50, 95% Confidence Interval [CI] 1.08 to 2.08, P = .002). CONCLUSION Rest-stress MPI appears safe in patients with mildly abnormal hs-cTn values, and the yield for detecting ischemia is associated with the HEART score, though further validation studies are needed.
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Affiliation(s)
- Arooj Khan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Rakesh Engineer
- Department of Emergency Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sihe Wang
- Department of Pathology and Laboratory Medicine, Akron Children's Hospital, Akron, OH, USA
| | - Wael A Jaber
- Department of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Venu Menon
- Department of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Paul C Cremer
- Department of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA.
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Pezel T, Garot P, Hovasse T, Unterseeh T, Champagne S, Toupin S, Sanguineti F, Lima JAC, Garot J. Prognostic value of pre-hospitalization stress perfusion cardiovascular magnetic resonance to predict death in patients hospitalized for COVID-19. Arch Cardiovasc Dis 2021; 114:781-792. [PMID: 34802962 PMCID: PMC8556590 DOI: 10.1016/j.acvd.2021.10.004] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 11/22/2022]
Abstract
Background Inducible ischaemia is a strong marker of vascular vulnerability. Knowing the important role of the vascular tropism of COVID-19 to explain its severity, the presence of a prior inducible ischaemia may be a key pathogenetic determinant of COVID-19 severity. Aims To investigate the prognostic value of prior inducible ischaemia on stress cardiovascular magnetic resonance (CMR) to predict death in patients hospitalized for COVID-19. Methods We retrospectively analysed consecutive patients referred for stress perfusion CMR during 1/1/18–1/1/20 who were later hospitalized for COVID-19. The primary outcome was all-cause death, including in-hospital and post-hospitalization deaths, based on the electronic national death registry. Results Among the patients referred for stress CMR, 481 were hospitalized for COVID-19 (mean age 68.4 ± 9.6 years, 61.3% male) and completed the follow-up (median [interquartile range] 73 [36–101] days). There were 93 (19.3%) all-cause deaths, of which 13.7% occurred in hospital and 5.6% were post-hospitalization deaths. Age, male sex, hypertension, diabetes, known coronary artery disease (CAD), the presence of prior inducible ischaemia, the number of ischaemic segments, the presence of late gadolinium enhancement and left ventricular ejection fraction were significantly associated with all-cause death. In multivariable stepwise Cox regression analysis, age (hazard ratio [HR]: 1.04, 95% confidence interval [CI]: 1.01–1.07; P = 0.023), hypertension (HR: 2.77; 95% CI: 1.71–4.51; P < 0.001), diabetes (HR: 1.72; 95% CI: 1.08–2.74; P = 0.022), known CAD (HR: 1.78; 95% CI: 1.07–2.94; P = 0.025) and prior inducible ischaemia (HR 2.05; 95% CI: 1.27–3.33; P = 0.004) were independent predictors of all-cause death. Conclusions In COVID-19 patients, prior inducible ischaemia by stress CMR during the 2 years preceding the COVID-19 pandemic was independently associated with all-cause death.
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Affiliation(s)
- Théo Pezel
- Institut cardiovasculaire Paris Sud, cardiovascular magnetic resonance laboratory, hôpital privé Jacques-Cartier, Ramsay Santé, Massy, France; Division of cardiology, Johns Hopkins hospital, Baltimore, Maryland, USA; Department of cardiology, Lariboisière hospital, AP-HP, Inserm UMRS 942, university of Paris, Paris, France
| | - Philippe Garot
- Institut cardiovasculaire Paris Sud, cardiovascular magnetic resonance laboratory, hôpital privé Jacques-Cartier, Ramsay Santé, Massy, France
| | - Thomas Hovasse
- Institut cardiovasculaire Paris Sud, cardiovascular magnetic resonance laboratory, hôpital privé Jacques-Cartier, Ramsay Santé, Massy, France
| | - Thierry Unterseeh
- Institut cardiovasculaire Paris Sud, cardiovascular magnetic resonance laboratory, hôpital privé Jacques-Cartier, Ramsay Santé, Massy, France
| | - Stéphane Champagne
- Institut cardiovasculaire Paris Sud, cardiovascular magnetic resonance laboratory, hôpital privé Jacques-Cartier, Ramsay Santé, Massy, France
| | | | - Francesca Sanguineti
- Institut cardiovasculaire Paris Sud, cardiovascular magnetic resonance laboratory, hôpital privé Jacques-Cartier, Ramsay Santé, Massy, France
| | - João A C Lima
- Division of cardiology, Johns Hopkins hospital, Baltimore, Maryland, USA
| | - Jérôme Garot
- Institut cardiovasculaire Paris Sud, cardiovascular magnetic resonance laboratory, hôpital privé Jacques-Cartier, Ramsay Santé, Massy, France.
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Thornton HC, Hanna F, Mullur K. Performance and Interpretation of Office Exercise Stress Testing. Prim Care 2021; 48:627-43. [PMID: 34752274 DOI: 10.1016/j.pop.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In an era where cardiovascular disease continues to increase in prevalence, chest pain is a commonly encountered complaint in the outpatient setting. Clinicians are often tasked with the challenge of selecting the most appropriate screening tool in the evaluation of a patient with suspected coronary artery disease. With proper consideration of indications and contraindications, exercise electrocardiogram (ECG) stress testing is an accessible, cost-conscious, and validated outpatient diagnostic modality for predicting coronary artery disease.
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21
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Banerjee A, Binder J, Salama R, Trant JF. Synthesis, characterization and stress-testing of a robust quillaja saponin stabilized oil-in-water phytocannabinoid nanoemulsion. J Cannabis Res 2021; 3:43. [PMID: 34556180 PMCID: PMC8461879 DOI: 10.1186/s42238-021-00094-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 11/02/2020] [Accepted: 08/05/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This study describes the design, optimization, and stress-testing of a novel phytocannabinoid nanoemulsion generated using high-pressure homogenization. [Formula: see text], a plant-derived commercial emulsifier containing quillaja saponin, was used to stabilize the lipid phase droplets in water. Stress-testing was performed on this nanoemulsion in order to evaluate its chemical and colloidal stability under the influence of different environmental factors, encompassing both physical and chemical stressors. METHODS Extensive optimization studies were conducted to arrive at an ideal nanoemulsion formulation. A coarse emulsion containing 16.6 wt% CBD-enriched cannabis distillate and 83.4 wt% carrier (soybean) oil dispersed in 10 wt% [Formula: see text] (1.5 wt% quillaja saponin) solution after 10 homogenization cycles at a pressure of 30,000 psi produced a stable nanoemulsion. This nanoemulsion was then subjected to the stress studies. RESULTS The optimized nanoemulsion had an average droplet diameter of ca. 120 nm and average droplet surface ζ potentials of ca. -30 mV. It was imaged and characterized by a variety of protocols. It proved to be stable to droplet agglomeration and phase separation upon storage under ambient conditions for 6 weeks, as well as under a variety of physical stressors such as heat, cold, dilution, and carbonation. pH values ≤2 and moderately high salt concentrations (> 100 mM), however, destabilized the nanoemulsion, eventually leading to phase separation. Cannabis potency, determined by HPLC, was detrimentally affected by any changes in the nanoemulsion phase stability. CONCLUSIONS Quillaja saponin stabilized cannabidiol(CBD)-enriched nanoemulsions are stable, robust systems even at low emulsifier concentrations, and are therefore significant from both a scientific as well as a commercial perspective.
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Affiliation(s)
- Abhinandan Banerjee
- Department of Chemistry and Biochemistry, University of Windsor, 401 Sunset Ave., Windsor, ON, Canada
| | | | - Rayan Salama
- Department of Chemistry and Biochemistry, University of Windsor, 401 Sunset Ave., Windsor, ON, Canada
| | - John F. Trant
- Department of Chemistry and Biochemistry, University of Windsor, 401 Sunset Ave., Windsor, ON, Canada
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Vidal-Perez R, Bouzas-Mosquera A, Peteiro J, Vazquez-Rodriguez JM. ISCHEMIA trial: How to apply the results to clinical practice. World J Cardiol 2021; 13:237-242. [PMID: 34589162 PMCID: PMC8436687 DOI: 10.4330/wjc.v13.i8.237] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/27/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
During the last years two questions have been continuously asked in chronic coronary syndromes: (1) Do revascularization procedures (coronary artery bypass grafting or percutaneous coronary intervention) really improve symptoms of angina? and (2) Do these techniques improve outcomes, i.e. do they prevent new myocardial infarction events and cardiovascular death? Therefore, there was a need for a large definitive trial. This study was the ISCHEMIA trial, a large, multicentric trial sponsored by the National Heart, Lung, and Blood Institute. The main trial compared coronary revascularization and optimal medical treatment (OMT) vs OMT alone in 5179 patients enrolled after a stress test. During a median 3.2-year follow-up, 318 primary outcome events occurred; the adjusted hazard ratio for the invasive strategy as compared with the conservative strategy was 0.93 (95% confidence interval 0.80-1.08, P = 0.34). The ISCHEMIA trial deeply disrupted many of our prior attitudes regarding management strategies for patients with stable coronary artery disease. The findings underscore the benefits of disease-modifying OMT for stable coronary artery disease patients. The main purposes of ischemia assessment before this trial were: Diagnostic purposes, assessment of outcome, and adding to decision-making processes. Obviously, this changed after the trial results. The results of ISCHEMIA might challenge the current diagnostic approach for stable angina patients recommended in the last European Society of Cardiology guidelines on chronic coronary disease that were based on studies published before the ISCHEMIA trial. In this editorial we propose our approach based on the ISCHEMIA study and the pretest probability for a positive test in patients with chronic coronary syndromes.
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Affiliation(s)
- Rafael Vidal-Perez
- Servicio de Cardiología, Unidad de Imagen y Función Cardíaca, Complexo Hospitalario Universitario A Coruña (CHUAC) Centro de Investigación Biomédica en Red (CIBERCV)-Instituto de Salud Carlos III, A Coruña 15006, Spain
| | - Alberto Bouzas-Mosquera
- Servicio de Cardiología, Unidad de Imagen y Función Cardíaca, Complexo Hospitalario Universitario A Coruña (CHUAC) Centro de Investigación Biomédica en Red (CIBERCV)-Instituto de Salud Carlos III, A Coruña 15006, Spain
| | - Jesus Peteiro
- Servicio de Cardiología, Unidad de Imagen y Función Cardíaca, Complexo Hospitalario Universitario A Coruña (CHUAC) Centro de Investigación Biomédica en Red (CIBERCV)-Instituto de Salud Carlos III, A Coruña 15006, Spain
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Abreu JC, Mahr AG, do Lago CL. Stability-indicating method development for quantification of bromopride, its impurities, and degradation products by ultra-high performance liquid chromatography applying Analytical Quality by Design principles. J Pharm Biomed Anal 2021; 205:114306. [PMID: 34385016 DOI: 10.1016/j.jpba.2021.114306] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 03/05/2021] [Revised: 07/20/2021] [Accepted: 07/30/2021] [Indexed: 11/25/2022]
Abstract
A comprehensive forced degradation study for bromopride was carried out in accordance with International Conference on Harmonization (ICH) recommendations followed by the identification and prospecting of the major degradation products. The analytical quality by design (AQbD) concepts were used to develop a stability-indicating method for bromopride and five organic impurities quantitation by ultra-high performance liquid chromatography with UV detection (UHPLC-UV). Two screenings and one optimization design were performed, including a Monte Carlo simulation to assess the Method Operable Design Region (MODR). The AQbD approach provided a high degree of method understanding in a very short period of time, less than two weeks, and the validated MODR provided information on robust analytical conditions contributing to the assignment of suitable control strategies.
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Affiliation(s)
- Juliana Caldeira Abreu
- Department of Fundamental Chemistry, Institute of Chemistry, University of São Paulo, Av. Prof. Lineu Prestes 748, SP, 05508-900, São Paulo, Brazil
| | - Amanda Guiraldelli Mahr
- Department of Fundamental Chemistry, Institute of Chemistry, University of São Paulo, Av. Prof. Lineu Prestes 748, SP, 05508-900, São Paulo, Brazil
| | - Claudimir Lucio do Lago
- Department of Fundamental Chemistry, Institute of Chemistry, University of São Paulo, Av. Prof. Lineu Prestes 748, SP, 05508-900, São Paulo, Brazil.
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Oikonomou EK, Van Dijk D, Parise H, Suchard MA, de Lemos J, Antoniades C, Velazquez EJ, Miller EJ, Khera R. A phenomapping-derived tool to personalize the selection of anatomical vs. functional testing in evaluating chest pain (ASSIST). Eur Heart J 2021; 42:2536-2548. [PMID: 33881513 PMCID: PMC8488385 DOI: 10.1093/eurheartj/ehab223] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/14/2021] [Accepted: 03/31/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS Coronary artery disease is frequently diagnosed following evaluation of stable chest pain with anatomical or functional testing. A more granular understanding of patient phenotypes that benefit from either strategy may enable personalized testing. METHODS AND RESULTS Using participant-level data from 9572 patients undergoing anatomical (n = 4734) vs. functional (n = 4838) testing in the PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) trial, we created a topological representation of the study population based on 57 pre-randomization variables. Within each patient's 5% topological neighbourhood, Cox regression models provided individual patient-centred hazard ratios for major adverse cardiovascular events and revealed marked heterogeneity across the phenomap [median 1.11 (10th to 90th percentile: 0.52-2.61]), suggestive of distinct phenotypic neighbourhoods favouring anatomical or functional testing. Based on this risk phenomap, we employed an extreme gradient boosting algorithm in 80% of the PROMISE population to predict the personalized benefit of anatomical vs. functional testing using 12 model-derived, routinely collected variables and created a decision support tool named ASSIST (Anatomical vs. Stress teSting decIsion Support Tool). In both the remaining 20% of PROMISE and an external validation set consisting of patients from SCOT-HEART (Scottish COmputed Tomography of the HEART Trial) undergoing anatomical-first vs. functional-first assessment, the testing strategy recommended by ASSIST was associated with a significantly lower incidence of each study's primary endpoint (P = 0.0024 and P = 0.0321 for interaction, respectively), as well as a harmonized endpoint of all-cause mortality or non-fatal myocardial infarction (P = 0.0309 and P < 0.0001 for interaction, respectively). CONCLUSION We propose a novel phenomapping-derived decision support tool to standardize the selection of anatomical vs. functional testing in the evaluation of stable chest pain, validated in two large and geographically diverse clinical trial populations.
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Affiliation(s)
- Evangelos K Oikonomou
- Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - David Van Dijk
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Department of Computer Science, Yale University, 51 Prospect St, New Haven, CT 06520-8285, USA
| | - Helen Parise
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Marc A Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California, 650 Charles E. Young Drive S, Los Angeles, CA 90095, USA
- Departments of Computational Medicine and Human Genetics, David Geffen School of Medicine at UCLA, University of California, 695 Charles E. Young Drive S, Los Angeles, CA 90095, USA
| | - James de Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8830, USA
| | - Charalambos Antoniades
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, UK
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, MS 1 Church Street, Suite 200, New Haven, CT 06510, USA
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25
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Pezel T, Unterseeh T, Garot P, Hovasse T, Kinnel M, Champagne S, Toupin S, Sanguineti F, Garot J. Prognostic value of vasodilator stress perfusion cardiovascular magnetic resonance after inconclusive stress testing. J Cardiovasc Magn Reson 2021; 23:89. [PMID: 34218805 PMCID: PMC8256486 DOI: 10.1186/s12968-021-00785-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 02/12/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND While current guidelines recommend noninvasive testing to detect coronary artery disease, stress tests are deemed inconclusive in a quarter of cases. The strategy for risk stratification after inconclusive stress testing is not well standardized. To assess the prognostic value of vasodilator stress cardiovascular magnetic resonance (CMR) parameters and CMR-based coronary revascularization in patients after inconclusive stress testing. METHODS Between 2008 and 2020, consecutive patients with a first non-CMR inconclusive stress test referred for vasodilator stress perfusion CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. CMR-related coronary revascularization was defined as any revascularisation occurring within 90 days after CMR. Univariable and multivariable Cox regressions were performed to determine the prognostic value of each parameter. RESULTS Of 1563 patients who completed the CMR protocol, 1402 patients (66.7% male, 69.5 ± 11.0 years) completed the follow-up (median [interquartile range], 6.5 [5.6-7.5] years); 197 experienced a MACE (14.1%). Vasodilator stress CMR was well tolerated without severe adverse events. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 2.88 [95% CI 2.18-3.81]; and HR: 1.46 [95% CI 1.16-1.89], both p < 0.001; respectively). In multivariable Cox regression, the presence and extent of inducible ischemia were independent predictors of a higher incidence of MACE (HR: 2.53 [95% CI 1.89-3.40]; and HR: 1.58 [95% CI 1.47-1.71]; both p < 0.001; respectively). After adjustment, the extent of inducible ischemia showed the best improvement in model discrimination above traditional risk factors (C-statistic 0.75 [95% CI 0.69-0.81] with C-statistic improvement: 0.12). The study suggested no benefit of CMR-related coronary revascularization in reducing MACE. CONCLUSIONS In patients with a first non-CMR inconclusive stress test, vasodilator stress CMR has good prognostic value to predict MACE offering an incremental prognostic value over traditional risk factors.
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Affiliation(s)
- Théo Pezel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, 21287-0409, USA
| | - Thierry Unterseeh
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Thomas Hovasse
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Marine Kinnel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Stéphane Champagne
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Solenn Toupin
- Siemens Healthcare France, 93200, Saint-Denis, France
| | - Francesca Sanguineti
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Jérôme Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
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26
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Ashburn NP, Smith ZP, Hunter KJ, Hendley NW, Mahler SA, Hiestand BC, Stopyra JP. The disutility of stress testing in low-risk HEART Pathway patients. Am J Emerg Med 2021; 45:227-232. [PMID: 33041122 PMCID: PMC8962568 DOI: 10.1016/j.ajem.2020.08.032] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The HEART Pathway identifies low-risk chest pain patients for discharge from the Emergency Department without stress testing. However, HEART Pathway recommendations are not always followed. The objective of this study is to determine the frequency and diagnostic yield of stress testing among low-risk patients. METHODS An academic hospital's chest pain registry was analyzed for low-risk HEART Pathway patients (HEAR score ≤ 3 with non-elevated troponins) from 1/2017 to 7/2018. Stress tests were reviewed for inducible ischemia. Diagnostic yield was defined as the rate of obstructive CAD among patients with positive stress testing. T-test or Fisher's exact test was used to test the univariate association of age, sex, race/ethnicity, and HEAR score with stress testing. Multivariate logistic regression was used to determine the association of age, sex, race/ethnicity, and HEAR score with stress testing. RESULTS There were 4743 HEART Pathway assessments, with 43.7% (2074/4743) being low-risk. Stress testing was performed on 4.1% (84/2074). Of the 84 low-risk patients who underwent testing, 8.3% (7/84) had non-diagnostic studies and 2.6% (2/84) had positive studies. Among the 2 patients with positive studies, angiography revealed that 1 had widely patent coronary arteries and the other had multivessel obstructive coronary artery disease, making the diagnostic yield of stress testing 1.2% (1/84). Each one-point increase in HEAR score (aOR 2.17, 95% CI 1.45-3.24) and being male (aOR 1.59, 95% CI 1.02-2.49) were associated with testing. CONCLUSIONS Stress testing among low-risk HEART Pathway patients was uncommon, low yield, and more likely in males and those with a higher HEAR score.
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Affiliation(s)
- Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States.
| | - Zachary P Smith
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Kale J Hunter
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Nella W Hendley
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States; Departments of Epidemiology and Prevention and Implementation Science, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Brian C Hiestand
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States
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Sojitra C, Dholakia C, Sudhakar P, Singh KK, Agarwal S. Identification of degradation impurity of TGR5 receptor agonist-ZY12201 by LC-MS technique during force degradation study. SN Appl Sci 2021; 3:660. [PMID: 34056545 PMCID: PMC8144688 DOI: 10.1007/s42452-021-04660-y] [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: 01/14/2021] [Accepted: 05/13/2021] [Indexed: 11/03/2022] Open
Abstract
Forced degradation study is a systemic characterization of degradation products of active pharmaceutical ingredient (API) at conditions which posses more harsh environment that accelerates degradation of API. Forced degradation and stability studies would be useful in selection of proper, packaging material and storage conditions of the API. These are also useful to demonstrate degradation pathways and degradation products of the API and further characterisation of the degradation products using mass spectrometry. TGR5 is a G protein-coupled receptor, activation of which promotes secretion of glucagon-like peptide-1 (GLP-1) and modulates insulin secretion. The potent and orally bioavailable TGR5 agonist, ZY12201, shows activation of TGR5 which increase secretion of GLP-1 and help in lowering blood glucose level in animal models. Hence it is necessary to establish and study degradation pathway and stability of API for better handling and regulatory approval. Force degradation studies of ZY12201 have shown presence of one oxidative impurity during oxidative degradation in HPLC analysis. The oxidized product is further characterized by LC-MS to elucidate structure of impurity and characterize its degradation pathway. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s42452-021-04660-y.
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Affiliation(s)
- Chandrakant Sojitra
- API Division, Cadila Healthcare Limited, Sarkhej-Bavla N.H. No. 8 A, Changodar, Ahmedabad, 382 210 India
- Department of Chemistry, Faculty of Science, M.S. University of Baroda, Baroda, 390 002 India
- Zydus Research Centre, Cadila Healthcare Ltd., Sarkhej-Bavla N.H. No. 8 A, Moraiya, Ahmedabad, 382 210 India
| | - Chintan Dholakia
- API Division, Cadila Healthcare Limited, Sarkhej-Bavla N.H. No. 8 A, Changodar, Ahmedabad, 382 210 India
| | - Padmaja Sudhakar
- Department of Chemistry, Faculty of Science, M.S. University of Baroda, Baroda, 390 002 India
| | - Kumar K. Singh
- API Division, Cadila Healthcare Limited, Sarkhej-Bavla N.H. No. 8 A, Changodar, Ahmedabad, 382 210 India
| | - Sameer Agarwal
- Zydus Research Centre, Cadila Healthcare Ltd., Sarkhej-Bavla N.H. No. 8 A, Moraiya, Ahmedabad, 382 210 India
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Abstract
The outbreak of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has presented a global public health emergency. Although predominantly a pandemic of acute respiratory disease, corona virus infectious disease-19 (COVID-19) results in multi-organ damage that impairs cardiopulmonary (CP) function and reduces cardiorespiratory fitness. Superimposed on the CP consequences of COVID-19 is a marked reduction in physical activity that exacerbates CP disease (CPD) risk. CP exercise testing (CPET) is routinely used in clinical practice to diagnose CPD and assess prognosis; assess cardiovascular safety for rehabilitation; and delineate the physiological contributors to exercise intolerance and exertional fatigue. As such, CPET plays an important role in clinical assessments of convalescent COVID-19 patients as well as research aimed at understanding the long-term health effects of SARS-CoV-2 infection. However, due to the ventilatory expired gas analysis involved with CPET, the procedure is considered an aerosol generating procedure. Therefore, extra precautions should be taken by health care providers and exercise physiologists performing these tests. This paper provides recommendations for CPET testing during the COVID-19 pandemic. These recommendations include indications for CPET; pre-screening assessments; precautions required for testing; and suggested decontamination protocols. These safety recommendations are aimed at preventing SARS-CoV-2 transmission during CPET.
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Affiliation(s)
- Virginia L Mihalick
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - Justin M Canada
- Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL, USA
| | - Ross Arena
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL, USA; Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Antonio Abbate
- Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL, USA
| | - Danielle L Kirkman
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, VA, USA.
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Kovač L, Črnugelj M, Roškar R, Trdan Lušin T, Časar Z. Understanding of cabotegravir degradation through isolation and characterization of key degradation products and kinetic studies. J Pharm Biomed Anal 2021; 201:114096. [PMID: 33957367 DOI: 10.1016/j.jpba.2021.114096] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
Cabotegravir is a novel human immunodeficiency virus integrase enzyme inhibitor used for prevention and treatment of HIV infection. The combinational final dosage form, as extended release injection suspension in combination with rilpivirine and as cabotegravir tablets (for lead-in therapy), was recently approved in Canada, EU and in USA and is currently seeking approval also in other countries. The subject of this investigation was to study the degradation of cabotegravir under different stress conditions as per the International Council for Harmonization (ICH) guidelines. The drug substance was found to be stable in thermal, photolytic and basic stress conditions, but degraded under acidic and oxidative stress conditions. It was determined that four main degradation products of cabotegravir are formed in forced degradation studies. All four main degradation products were isolated using preparative chromatography and subjected to NMR and HRMS analysis in order to determine their structure. We proposed degradation pathways of cabotegravir under acidic stress conditions in solution based on the structure of isolated degradation products, cabotegravir degradation kinetic studies and degradation studies on two isolated key degradation products. Moreover, degradation pathway to predominant oxidation degradation product is proposed based on the adduct of cabotegravir and peroxide species, which was identified by LC-HRMS analysis. This is the first report to the best of our knowledge that describes characterized cabotegravir forced degradation impurities and provides insights into its degradation pathways.
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Affiliation(s)
- Lidija Kovač
- University of Ljubljana, Faculty of Pharmacy, Aškerčeva c. 7, SI-1000, Ljubljana, Slovenia; Lek Pharmaceuticals d.d., Sandoz Development Center Slovenia, Analytics Department, Verovškova ulica 57, SI-1526, Ljubljana, Slovenia
| | - Martin Črnugelj
- Lek Pharmaceuticals d.d., Sandoz Development Center Slovenia, Analytics Department, Verovškova ulica 57, SI-1526, Ljubljana, Slovenia
| | - Robert Roškar
- University of Ljubljana, Faculty of Pharmacy, Aškerčeva c. 7, SI-1000, Ljubljana, Slovenia
| | - Tina Trdan Lušin
- University of Ljubljana, Faculty of Pharmacy, Aškerčeva c. 7, SI-1000, Ljubljana, Slovenia; Lek Pharmaceuticals d.d., Sandoz Development Center Slovenia, Analytics Department, Verovškova ulica 57, SI-1526, Ljubljana, Slovenia
| | - Zdenko Časar
- University of Ljubljana, Faculty of Pharmacy, Aškerčeva c. 7, SI-1000, Ljubljana, Slovenia; Lek Pharmaceuticals d.d., Sandoz Development Center Slovenia, Analytics Department, Verovškova ulica 57, SI-1526, Ljubljana, Slovenia.
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Pezel T, Unterseeh T, Kinnel M, Hovasse T, Sanguineti F, Toupin S, Champagne S, Garot P, Garot J. Long-term prognostic value of stress perfusion cardiovascular magnetic resonance in patients without known coronary artery disease. J Cardiovasc Magn Reson 2021; 23:43. [PMID: 33827603 PMCID: PMC8028337 DOI: 10.1186/s12968-021-00737-0] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 02/21/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND To assess the incremental long-term prognostic value of vasodilator stress perfusion cardiovascular magnetic resonance (CMR) in patients without known coronary artery disease (CAD). METHODS Between 2010 and 2011, consecutive patients with cardiovascular risk factors without known CAD referred for stress CMR were followed for the occurrence of major adverse cardiac events (MACE), defined by cardiovascular mortality or recurrent non-fatal myocardial infarction (MI). Uni- and multivariable Cox regressions were performed to determine the prognostic value of ischemia and unrecognized MI defined by sub-endocardial or transmural late gadolinium enhancement (LGE). RESULTS Among 2,295 patients without known CAD, 2058 (89.7%) (71.2 ± 12.5 years; 37.5% males) completed the follow-up (median [IQR]: 8.3 [7.3-8.7] years), and 203 had MACE (9.9%). Using Kaplan-Meier analysis, ischemia and unrecognized MI were associated with MACE (hazard ratio, HR: 4.64 95% CI: 3.69-6.17 and HR: 2.88; 95% CI: 2.08-3.99, respectively; both p < 0.001). In multivariable stepwise Cox regression, ischemia and unrecognized MI were independent predictors of MACE (HR = 3.71; 95% CI 2.73-5.05, p < 0.001 and HR = 1.73; 95% CI 1.22-2.45, p = 0.002; respectively) and cardiovascular mortality (HR: 3.13; 95% CI: 2.17-4.51, p < 0.001 and HR = 1.73; 95% CI 1.15-2.62, p = 0.009; respectively). The addition of ischemia and unrecognized MI led to an improved model discrimination for MACE (change in C statistic from 0.61 to 0.72; NRI = 0.431; IDI = 0.053). CONCLUSIONS Inducible ischemia and unrecognized MI identified by stress CMR have incremental long term prognostic value for the incidence of MACE in patients without known CAD over traditional risk factors and left ventricular ejection fraction.
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Affiliation(s)
- Théo Pezel
- CMR Department, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, 21287-0409, USA
| | - Thierry Unterseeh
- CMR Department, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Marine Kinnel
- CMR Department, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Thomas Hovasse
- CMR Department, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Francesca Sanguineti
- CMR Department, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Solenn Toupin
- Siemens Healthcare France, 93200, Saint-Denis, France
| | - Stéphane Champagne
- CMR Department, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Philippe Garot
- CMR Department, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Jérôme Garot
- CMR Department, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
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Pezel T, Hovasse T, Kinnel M, Unterseeh T, Champagne S, Toupin S, Garot P, Sanguineti F, Garot J. Prognostic value of stress cardiovascular magnetic resonance in asymptomatic patients with known coronary artery disease. J Cardiovasc Magn Reson 2021; 23:19. [PMID: 33678173 PMCID: PMC7938489 DOI: 10.1186/s12968-021-00721-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 10/13/2020] [Accepted: 01/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several studies have established the prognostic value of vasodilator stress cardiovascular magnetic resonance (CMR) in broad population of patients with suspected or known coronary artery disease (CAD), but this specific population of asymptomatic patients with known CAD have never been formally evaluated. To assess the long-term prognostic value of vasodilator stress perfusion CMR in asymptomatic patients with obstructive CAD. METHODS Between 2009 and 2011, consecutive asymptomatic patients with obstructive CAD referred for vasodilator stress CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular mortality or recurrent non-fatal myocardial infarction (MI). Uni- and multivariable Cox regressions were performed to determine the prognostic value of myocardial ischemia and myocardial infarction defined by late gadolinium enhancement (LGE) with ischemic pattern. RESULTS Among 1529 asymptomatic patients with obstructive CAD, 1342 (87.8%; 67.7 ± 10.5 years, 82.0% males) completed the follow-up (median 8.3 years), and 195 had MACE (14.5%). Patients without stress-induced myocardial ischemia had a low annualized rate of MACE (2.4%), whereas the annualized rate of MACE was higher for patients with mild, moderate, or severe ischemia (7.3%, 16.8%, and 42.2%, respectively; ptrend < 0.001). Using Kaplan-Meier analysis, myocardial ischemia and LGE were associated with MACE (hazard ratio, HR 2.52; 95% CI 1.90-3.34 and HR 2.04; 95% CI 1.38-3.03, respectively; both p < 0.001). In multivariable stepwise Cox regression, myocardial ischemia and LGE were independent predictors of MACE (HR 2.80 95% CI 2.10-3.73, p < 0.001 and HR 1.51; 95% CI 1.01-2.27, p = 0.045; respectively). The addition of myocardial ischemia and LGE led to improved model discrimination for MACE (change in C statistic from 0.61 to 0.68; NRI = 0.207; IDI = 0.021). CONCLUSIONS Vasodilator stress CMR-induced myocardial ischemia and LGE are good long-term predictors for the incidence of MACE in asymptomatic patients with obstructive CAD.
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Affiliation(s)
- Théo Pezel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, 21287-0409, USA
| | - Thomas Hovasse
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Marine Kinnel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Thierry Unterseeh
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Stéphane Champagne
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Solenn Toupin
- Siemens Healthcare France, 93200, Saint-Denis, France
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Francesca Sanguineti
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Jérôme Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
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Columbo JA, Demsas F, Wanken ZJ, Suckow BD, Beach JM, Henkin S, Goodney PP, Stone DH. Stress testing before abdominal aortic aneurysm repair does not lead to a reduction in perioperative cardiac events. J Vasc Surg 2021; 74:694-700. [PMID: 33684471 DOI: 10.1016/j.jvs.2021.02.032] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/21/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Stress testing is often used before abdominal aortic aneurysm (AAA) repair. Whether stress testing leads to a reduction in cardiac events after AAA repair has remained unclear. Our objective was to study the national stress test usage rates and compare the perioperative outcomes between centers with high and low usage of stress testing. METHODS We used the Vascular Quality Initiative to study patients who had undergone elective endovascular AAA repair (EVAR) or open AAA repair (OAR). We measured the usage rates of stress testing across centers and compared the Vascular Study Group of New England cardiac risk index (VSG-CRI) among patients who had and had not undergone preoperative stress testing. We determined the rate of major adverse cardiac events (MACE), a composite of perioperative myocardial infarction, stroke, heart failure exacerbation, and death across the centers. We compared the MACE and 1-year mortality between the centers in the highest quintile of stress test usage and the lowest quintile. RESULTS We studied 43,396 EVAR patients and 8935 OAR patients across 324 centers. The median proportion of stress test usage across centers before EVAR was 35.9% and varied from 10.2% (5th percentile) to 73.7% (95th percentile), with similar variability for OAR (median, 57.9%; 5th percentile, 13.0%; 95th percentile, 86.0%). The mean VSG-CRI for the EVAR group with preoperative stress testing was 5.6 ± 2.1 compared with 5.4 ± 2.1 (P < .001) for the EVAR group without preoperative stress testing. The findings were similar for OAR, with a VSG-CRI of 5.1 ± 2.0 vs 4.8 ± 2.1 (P < .001) for those with and without preoperative stress testing, respectively. The rate of MACE was 1.8% after EVAR and 11.6% after OAR. The 1-year mortality was 4.6% for EVAR and 6.6% for OAR. The centers in the highest quintile of stress testing had a higher adjusted likelihood of MACE after both EVAR (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.37-2.30) and OAR (OR, 1.99; 95% CI, 1.53-2.59) but similar 1-year mortality (EVAR: OR, 1.18; 95% CI, 1.02-1.37; OAR: OR, 0.87; 95% CI, 0.65-1.17) compared with the centers in the lowest quintile. The VSG-CRI was not different between the high stress test centers (EVAR, 5.5 ± 2.1; OAR: 5.0 ± 2.0), and low stress test centers (EVAR, 5.5 ± 2.1; P = .403; OAR, 4.9 ± 2.0; P = .563). CONCLUSIONS Stress test usage before AAA repair varied widely across Vascular Quality Initiative centers despite similar patient risk profiles. No reduction was observed in MACE or 1-year mortality among centers with high stress test usage. The value of routine stress testing before AAA repair should be reconsidered, and stress testing should be used more selectively, given these findings and the associated costs of widespread testing.
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Affiliation(s)
- Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Falen Demsas
- Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Zachary J Wanken
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Bjoern D Suckow
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Jocelyn M Beach
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Stanislav Henkin
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Cardiovascular Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
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Kurmi M, Suryavanshi V, Panduranga NS, Jayaraman K, Bajpai L, Fish W, Hu Y, Bhutani H. Development of HPLC-CAD stability indicating assay method for polyethylene glycol-conjugated phospholipid (DMPE-PEG 2000) and identification of its degradation products. J Pharm Biomed Anal 2021; 198:113967. [PMID: 33662758 DOI: 10.1016/j.jpba.2021.113967] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 01/26/2023]
Abstract
The study introduces first report on a liquid chromatographic method for the quantification of 1,2-Dimyristoyl-sn-glycero-3-phosphoethanolamine-N-[methoxy(polyethylene glycol)-2000] ammonium salt (DMPE-PEG 2000), which is an important constituent of lipid-based nanoparticles. It involves an HPLC-CAD stability-indicating assay method development for DMPE-PEG 2000 and structure elucidation of its degradation products. Hypersil Gold™ PFP column (150 mm × 4.6 mm, 3.0 μm) was used to achieve the separation among DMPE-PEG 2000 and its degradation products using 0.0025% formic acid in water: methanol (80:20 v/v) as mobile phase A and methanol: acetonitrile (60:40 v/v) as mobile phase B in a gradient elution mode. The method was validated for precision, linearity, sensitivity, solution stability and robustness. Relative standard deviations for the intra-day precision, inter-day precision and sensitivity were 1.6%, 0.6% and 3.8%, respectively. The method was linear in the range from 210 μg/mL to 390 μg/mL with R2 value of 0.996. Further, the solution stability of DMPE-PEG 2000 was evaluated under different stressed and storage conditions to understand the impact of any excursion to its regular storage temperature of -20 °C. The observed degradation products were identified through liquid chromatography high resolution mass spectrometry and a tentative pathway was proposed for the generation of these degradants.
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Affiliation(s)
- Moolchand Kurmi
- Analytical Research and Development, Biocon Bristol Myers Squibb Research and Development Centre (BBRC), Syngene International Limited, Bangalore 560099, India
| | - Vipul Suryavanshi
- Analytical Research and Development, Biocon Bristol Myers Squibb Research and Development Centre (BBRC), Syngene International Limited, Bangalore 560099, India
| | - Narayana Swamy Panduranga
- Analytical Research and Development, Biocon Bristol Myers Squibb Research and Development Centre (BBRC), Syngene International Limited, Bangalore 560099, India
| | - Karthik Jayaraman
- Analytical Research and Development, Biocon Bristol Myers Squibb Research and Development Centre (BBRC), Syngene International Limited, Bangalore 560099, India
| | - Lakshmikant Bajpai
- Analytical Research and Development, Biocon Bristol Myers Squibb Research and Development Centre (BBRC), Syngene International Limited, Bangalore 560099, India
| | - William Fish
- Drug Product Development, Bristol Myers Squibb Company, 1 Squibb Drive, New Brunswick, NJ 08903, USA
| | - Yue Hu
- Analytical Strategic Operations, Bristol Myers Squibb Company, 1 Squibb Drive, New Brunswick, NJ 08903, USA
| | - Hemant Bhutani
- Analytical Research and Development, Biocon Bristol Myers Squibb Research and Development Centre (BBRC), Bristol Myers Squibb India Private Limited, Bangalore 560099, India.
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Bian J, Herzog CA, Rangaswami J, Wald R, Stratman JA, Asif A, Sidhu MS, Bangalore S, Mathew RO. Lung Sestamibi Uptake on Myocardial Perfusion Imaging and Outcomes in Chronic Kidney Disease. Cardiorenal Med 2021; 11:67-76. [PMID: 33494087 DOI: 10.1159/000511801] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/19/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In patients with CKD and end-stage kidney disease (ESKD), cardiac stress testing has low sensitivity and specificity for coronary disease. Alternate markers that are derived during the stress testing may enhance the predictive characteristic of stress testing. The objective was to examine the predictive characteristic of lung-to-heart ratio (LHR) in patients with CKD and ESKD. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS Retrospective parallel cohort of ESKD and CKD not on dialysis (CKD-ND) who underwent stress testing with nuclear myocardial perfusion imaging utilizing sestamibi tracer and regadenoson. Stress LHR was calculated by the processing software and reported. Patients were analyzed by tertile of LHR (≤0.28, 0.29-0.32, ≥0.33). The primary outcome was a composite of all-cause mortality, hospitalization for myocardial infarction or unstable angina, or revascularization. RESULTS There were 144 CKD-ND and 145 ESKD patients. Patients with ESKD had greater comorbidity burden than CKD-ND. Stress tests were more often performed for pre-operative risk assessment among ESKD versus CKD-ND (53.8 vs. 5.6%, p < 0.001). ESKD patients more likely had ischemia identified on stress testing (19.3 vs. 8.3%, p = 0.001). Mean LHR was 0.31 (Standard deviation - SD: 0.09) and was similar across CKD-ND stages and ESKD. Primary outcome in the lowest (23%) and highest (33.3%) LHR tertile was higher than the middle tertile (12.8%); p = 0.005. This finding was similar between CKD-ND and ESKD and persisted in multivariable analysis. CONCLUSIONS LHR ≤0.28 and ≥0.33 are independently associated with higher risk for death in patients with CKD-ND and ESKD. Future studies are warranted to understand the association of extreme LHR values and outcomes in this high-risk population.
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Affiliation(s)
- Julia Bian
- University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Charles A Herzog
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare/University of Minnesota, Minneapolis, Minnesota, USA
| | - Janani Rangaswami
- Division of Nephrology, Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Ron Wald
- Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Ontario, Québec, Canada
| | - Jennifer A Stratman
- Education & Research, Columbia VA Health Care System, Columbia, South Carolina, USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, Hackensack-Meridian School of Medicine at Seton Hall University, Hackensack-Meridian Health, Neptune, New Jersey, USA
| | - Mandeep S Sidhu
- Division of Cardiology, Department of Medicine, Albany Medical College & Albany Medical Center, Albany, New York, USA
| | - Sripal Bangalore
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Roy O Mathew
- University of South Carolina School of Medicine, Columbia, South Carolina, USA, .,Division of Nephrology, Department of Medicine, Columbia VA Health Care System, Columbia, South Carolina, USA,
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Colbert CM, Shao J, Hollowed JJ, Currier JW, Ajijola OA, Fishbein GA, Duarte-Vogel SM, Dharmakumar R, Hu P, Nguyen KL. 3D-Printed Coronary Implants Are Effective for Percutaneous Creation of Swine Models with Focal Coronary Stenosis. J Cardiovasc Transl Res 2020; 13:1033-1043. [PMID: 32394352 PMCID: PMC9667863 DOI: 10.1007/s12265-020-10018-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Received: 11/22/2019] [Accepted: 04/28/2020] [Indexed: 01/17/2023]
Abstract
Reliable, closed-chest methods for creating large animal models of acute myocardial hypoperfusion are limited. We demonstrated the feasibility and efficacy of using magnetic resonance (MR)-compatible 3D-printed coronary implants for establishing swine models of myocardial hypoperfusion. We designed, manufactured, and percutaneously deployed implants in 13 swine to selectively create focal coronary stenosis. To test the efficacy of the implants to cause hypoperfusion or ischemia in the perfused territory, we evaluated regional wall motion, myocardial perfusion, and infarction using MR imaging. The overall swine survival rate was 85% (11 of 13). The implant retrieval rate was 92% (12 of 13). Fluoroscopic angiography confirmed focal stenosis. Cine and perfusion MRI showed regional wall motion abnormalities and inducible ischemia, respectively. Late gadolinium enhancement and histopathology showed no myocardial infarction. Our minimally invasive technique has promising applications for validation of new diagnostic methods in cardiac MR. Graphical abstract Our new minimally invasive, percutaneous method for creating swine models of acute focal coronary stenosis can be used for magnetic resonance imaging studies of myocardial ischemia. Comparable to existing methods in its efficacy and reliability, this rapid prototyping technique will allow researchers to more easily conduct translational cardiac imaging studies of coronary artery disease in large animal models.
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Affiliation(s)
- Caroline M Colbert
- Physics and Biology in Medicine Graduate Program, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jiaxin Shao
- Diagnostic Cardiovascular Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - John J Hollowed
- Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA, 90073, USA
| | - Jesse W Currier
- Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA, 90073, USA
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center and Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gregory A Fishbein
- Department of Pathology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sandra M Duarte-Vogel
- Division of Laboratory Animal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Rohan Dharmakumar
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center and Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peng Hu
- Physics and Biology in Medicine Graduate Program, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Diagnostic Cardiovascular Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kim-Lien Nguyen
- Physics and Biology in Medicine Graduate Program, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- Diagnostic Cardiovascular Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA, 90073, USA.
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Bird JG, Morant K, Al-Souri D, Scott CG, Padang R, McCully RB, Kane GC, Pellikka PA, Luis SA. Impact of Anemia on Exercise and Pharmacologic Stress Echocardiography. J Am Soc Echocardiogr 2020; 33:1067-1076. [PMID: 32709477 DOI: 10.1016/j.echo.2020.04.003] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The safety and diagnostic accuracy of stress testing in anemic patients have not been well studied. Despite a lack of data, significant anemia may be considered a relative contraindication to stress testing because of safety concerns related to insufficient myocardial oxygen supply. METHODS The authors reviewed 28,829 consecutive patients with blood hemoglobin drawn within 48 hours of stress echocardiography (15,624 exercise and 13,205 dobutamine). The associations of blood hemoglobin concentration with arrhythmia and other stress echocardiographic findings were examined. Additionally, the effect of anemia on the positive predictive value of stress echocardiography for the detection of significant coronary artery stenosis (≥50%) was assessed in patients who subsequently underwent coronary angiography. RESULTS Anemia was present in 6,401 patients (22.2%) and was severe (hemoglobin < 8.0 g/dL) in 52. Stress testing with either exercise or dobutamine was safe, with no significant increase in serious arrhythmia events or need for hospitalization. In the exercise cohort, worsening anemia was associated with reduced treadmill exercise time, lower peak heart rate, peak rate-pressure product, and achieved workload. In the dobutamine stress cohort, worsening anemia was associated with higher resting heart rate, more use of atropine, and fewer patients attaining target heart rate. The positive predictive value of stress echocardiography was higher in patients with moderate anemia compared with those without anemia (71.8% vs 60.2%, P = .01). CONCLUSIONS This study demonstrates that stress testing is safe in patients with mild and moderately anemia, albeit with a small increase in mild supraventricular arrhythmias with exercise. However, worsening anemia was associated with a significant reduction in exercise capacity. Additionally, worsening anemia was associated with an improvement in the positive predictive value of stress echocardiography. Extrapolation of these data to patients with severe anemia should be performed with caution given the limited number of patients with severe anemia in this study.
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Affiliation(s)
- Jared G Bird
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kareem Morant
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Deema Al-Souri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Sushil Allen Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Singh DK, Sahu A, Balhara A, Giri S, Singh S. Insights into the degradation chemistry of tazarotene, a third generation acetylenic retinoid: LC-HRMS (Orbitrap), LC-MS n and NMR characterization of its degradation products, and prediction of their physicochemical and ADMET properties. J Pharm Biomed Anal 2020; 186:113316. [PMID: 32413825 DOI: 10.1016/j.jpba.2020.113316] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 01/29/2020] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 02/02/2023]
Abstract
Tazarotene is a prodrug that belongs to the acetylenic class of retinoids. The drug was subjected to hydrolytic, oxidative and photolytic stress testing to establish its comprehensive degradation chemistry. The drug proved to be unstable under acidic and basic hydrolytic conditions, yielding tazarotenic acid, which is a known major degradation product (DP) and an active metabolite. Additionally, two DPs each were generated upon interaction of drug and tazarotenic acid with HCl, used as an acid stressor. These were experimentally proven as pseudo DPs, as they did not originate when H2SO4 was employed as the stressor. The drug was also unstable under oxidative and photolytic conditions, yielding six DPs. All the products were separated on reversed phase (C18) column, using mobile phase composed of 10 mM ammonium formate (pH 3.5) and acetonitrile, which was run in a gradient mode. The separated DPs were subjected to LC-HRMS and LC-MSn studies for their initial characterization. Seven hydrolytic and oxidative DPs that could be isolated using semi-preparative column were subjected to extensive 1D (1H, 13C and DEPT-135) and 2D (COSY, HSQC and HMBC) NMR studies to confirm their structures. In total, five novel DPs were characterized, apart from two previously reported DPs, viz., tazarotenic acid and tazarotene sulfoxide, and four additional pseudo DPs. The complete degradation pathway of the drug was established. In silico ADMET properties of the drug and its DPs were evaluated using ADMET Predictor™.
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Affiliation(s)
- Dilip Kumar Singh
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S. A. S. Nagar 160 062, Punjab, India
| | - Archana Sahu
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S. A. S. Nagar 160 062, Punjab, India
| | - Ankit Balhara
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S. A. S. Nagar 160 062, Punjab, India
| | - Sanjeev Giri
- DMPK and Pharmaceutical Development, Aurigene Discovery Technologies Limited, Hyderabad, 500 049, Telangana, India
| | - Saranjit Singh
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S. A. S. Nagar 160 062, Punjab, India.
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Ratwatte S, Costello B, Kangaharan N, Bolton K, Kaur A, Corkill W, Kuepper B, Pitman B, Sanders P, Wong CX. Clinical Utility of Stress Echocardiography in Remote Indigenous and Non-Indigenous Populations: A 10-Year Study in Central Australia. Heart Lung Circ 2020; 29:1808-1814. [PMID: 32586728 DOI: 10.1016/j.hlc.2020.04.013] [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] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 03/07/2020] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Remote Central Australia has a large Indigenous population and a significant burden of cardiovascular disease. Stress echocardiography has been previously validated as a useful investigation for long-term prognostication. However, there are no prior studies assessing its utility in remote or Indigenous populations. METHOD Consecutive individuals undergoing stress echocardiography in Central Australia between 2007 and 2017 were included. Stress echocardiography was performed and reported via standard protocols. Individuals were followed up for all-cause mortality. RESULTS One-thousand and eight patients (1,008) (54% Indigenous Australian) were included. After a mean follow-up of 3.5±2.4 years, 54 (5%) patients were deceased. Overall, 797 (79%) patients had no abnormalities during rest or stress echocardiography, with no difference according to ethnicity (p>0.05). In patients with a normal test, annual mortality averaged 1.3% over 5 years of follow-up, with annual mortality significantly higher in Indigenous compared to non-Indigenous individuals (1.8% vs 0.6% respectively). In those with an abnormal test, annual mortality was 4.4% vs 1.3% in Indigenous and non-Indigenous individuals respectively. Increasing age, Indigenous ethnicity and cardiometabolic comorbidities were associated with mortality in univariate analyses (p<0.05 for all). In multivariate models, only chronic kidney disease remained predictive of mortality, with other associations (including Indigenous ethnicity) becoming attenuated. CONCLUSION This is the first study to report on the use of stress echocardiography in a remote or Indigenous population. A normal stress echocardiogram in remote Indigenous individuals was able to identify a lower risk group of patients in this setting. Although Indigenous individuals with a normal test still had a higher annual rate of mortality compared to non-Indigenous individuals, this association appeared to be mediated by cardiometabolic comorbidities.
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Affiliation(s)
- Seshika Ratwatte
- University of Newcastle, Concord Repatriation and General Hospital, and Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Benedict Costello
- Baker IDI Heart & Diabetes Institute and Alfred Hospital, Melbourne, Vic, Australia
| | | | - Katrina Bolton
- Department of Cardiology, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Amrina Kaur
- Department of Cardiology, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Wendy Corkill
- Department of Cardiology, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Bernhard Kuepper
- Department of Cardiology, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Bradley Pitman
- University of Adelaide, Royal Adelaide Hospital, and South Australian Health & Medical Research Institute, Adelaide, SA, Australia
| | - Prashanthan Sanders
- University of Adelaide, Royal Adelaide Hospital, and South Australian Health & Medical Research Institute, Adelaide, SA, Australia
| | - Christopher X Wong
- University of Adelaide, Royal Adelaide Hospital, and South Australian Health & Medical Research Institute, Adelaide, SA, Australia.
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Murthy VL, Bateman TM, Chen W, Malhotra S, Miller E, Ruddy T, Dilsizian V. Impact of the ISCHEMIA Trial on Stress Nuclear Myocardial Perfusion Imaging. J Nucl Med 2020:jnumed.120.245399. [PMID: 32513904 DOI: 10.2967/jnumed.120.245399] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Timothy M Bateman
- Mid America Heart Institute and the Saint-Luke's Health System, United States
| | - Wengen Chen
- University of Maryland Medical Center, United States
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Nagel E, Carerj ML, Arendt CT, Puntmann VO. After ISCHEMIA: Is cardiac MRI a reliable gatekeeper for invasive angiography and myocardial revascularization? Herz 2020; 45:446-52. [PMID: 32458013 DOI: 10.1007/s00059-020-04936-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This review surveys the findings of the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial and puts them into a clinical perspective regarding its effect of the role of cardiac magnetic resonance imaging (CMR) as a well-validated gatekeeper for invasive angiography and myocardial revascularization. Noninvasive stress testing of patients with intermediate-to-high pretest likelihood for obstructive coronary artery disease (CAD) using perfusion CMR provides excellent diagnostic accuracy in detecting ischemic myocardium, and additional information from tissue characterization can guide the management of patients with stable angina toward a more individualized therapy as other non-coronary underlying causes of chest pain can be detected. Since ISCHEMIA failed to show that an invasive strategy using percutaneous coronary intervention or coronary artery bypass grafting was associated with an improved prognosis compared with initial conservative medical therapy among stable patients with moderate-to-severe ischemia, CMR as a multifaceted diagnostic imaging approach to explain patients' symptoms should be preferred over anatomical and stress testing alone. Nevertheless, the exclusion of left main coronary artery stenosis either by coronary CT or MR angiography may be required. In conclusion, the results of the ISCHEMIA trial are in good accordance with those of the MR-INFORM trial recently published in the New England Journal of Medicine, as the noninvasive management of a large proportion of patients with CAD was shown to be noninferior to current invasive strategies. Recent outcome data from trials may therefore have an impact on future guidelines to further reduce the execution of unnecessary left heart catheterizations.
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Columbo JA, Barnes JA, Jones DW, Suckow BD, Walsh DB, Powell RJ, Goodney PP, Stone DH. Adverse cardiac events after vascular surgery are prevalent despite negative results of preoperative stress testing. J Vasc Surg 2020; 72:1584-1592. [PMID: 32247699 DOI: 10.1016/j.jvs.2020.01.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 10/12/2019] [Accepted: 01/03/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Cardiac risk assessment is a critical component of vascular disease management before surgical intervention. The predictive risk reduction of a negative cardiac stress test result remains poorly defined. The objective of this study was to compare the incidence of postoperative cardiac events among patients with negative stress test results vs those who did not undergo testing. METHODS We reviewed all patients who underwent elective open abdominal aortic aneurysm repair, suprainguinal bypass, endovascular aneurysm repair (EVAR), carotid endarterectomy (CEA), and infrainguinal bypass within the Vascular Study Group of New England from 2003 to 2017. We excluded patients with positive stress test results (n = 3312) and studied two mutually exclusive groups: elective surgery patients with a negative stress test result and elective surgery patients with no stress test (total n = 26,910). The primary outcome was a composite of in-hospital postoperative cardiac events (dysrhythmia, heart attack, heart failure) or death. RESULTS A preoperative stress test was obtained in 66.3% of open repairs, 42.8% of suprainguinal bypasses, 37.1% of EVARs, 36.0% of CEAs, and 31.2% of infrainguinal bypasses. The proportion of patients receiving a preoperative stress test varied widely across centers, from 37.1% to 80.0%. The crude odds ratio of in-hospital postoperative cardiac event or death was 1.37 (95% confidence interval [CI], 1.07-1.76) for open repair and 1.52 (CI, 1.13-2.03) for suprainguinal bypass, indicating that patients with negative stress test results before these procedures were 37% and 52% more likely to suffer a postoperative event or die compared with patients selected to proceed directly to surgery without testing. Conversely, the crude odds ratio was 0.92 (CI, 0.66-1.29) for EVAR, 0.92 (CI, 0.70-1.21) for CEA, and 1.13 (CI, 0.90-1.40) for infrainguinal bypass, indicating that patients undergoing these procedures had a similar likelihood of sustaining an event whether they had a negative stress test result or proceeded directly to surgery without a stress test. CONCLUSIONS The use of cardiac stress testing before vascular surgery varies widely throughout New England. Whereas patients are often appropriately selected to proceed directly to surgery, a negative preoperative stress test result should not assuage the concern for an adverse outcome as these patients retain a substantial likelihood of cardiac events, especially after large-magnitude procedures.
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Affiliation(s)
- Jesse A Columbo
- Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - J Aaron Barnes
- Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Bjoern D Suckow
- Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Daniel B Walsh
- Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Richard J Powell
- Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Philip P Goodney
- Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - David H Stone
- Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH
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Leal A, Andrade R, Flores P, Silva FS, Fulkerson J, Neyret P, Arendt E, Espregueira-Mendes J. Unilateral anterior knee pain is associated with increased patellar lateral position after stressed lateral translation. Knee Surg Sports Traumatol Arthrosc 2020; 28:454-462. [PMID: 31375878 DOI: 10.1007/s00167-019-05652-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 03/14/2019] [Accepted: 07/26/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE To objectively compare side-to-side patellar position and mobility in patients with idiopathic unilateral anterior knee pain (AKP) using a stress-testing device concomitantly with magnetic resonance imaging. It is hypothesized that the painful knees present greater patellar mobility than the contralateral non-painful knees. METHODS From a total sample of 359 patients, 23 patients with idiopathic unilateral AKP (30.9 years, 23.4 kg/m2, 43% males) were included within the present study. Both knees of all the patients were examined by conventional imaging, including the measurement of trochlear sulcus angle, Caton-Deschamps index, tibial tuberosity to trochlear groove distance, patellar tilt angle and patellar subluxation (both at rest and upon quadriceps contraction). Additionally, the same patients underwent stress testing (Porto Patella Testing Device); these measurements were taken with the patella at rest, after lateral patellar translation and after lateral patellar tilt. Clinical and functional outcomes were obtained using physical examination and the Kujala and Lysholm scores. RESULTS Painful knees showed statistically significant higher patellar lateral position after stressed lateral translation than non-painful knees (p = 0.028), 9.8 ± 3.6 mm and 7.1 ± 6.3 mm, respectively. The adjusted multivariate logistic model identified the patellar position after lateral displacement to be significantly associated with AKP (OR = 1.165) and the model (AUC = 0.807, p < 0.001) showed reasonable sensitivity (67%) and specificity (73%). CONCLUSION Patients with idiopathic unilateral AKP with morphologically equivalent knees showed statistically significant increased patellar lateral position after stressed lateral displacement in their painful knee. The greater lateral patellar mobility quantified by the PPTD testing brings more objectivity to the diagnosis. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Ana Leal
- Mechanical Engineering Department, CMEMS Center for MicroElectroMechanical Systems, University of Minho, Guimarães, Portugal.,Dom Henrique Research Centre, Porto, Portugal
| | - Renato Andrade
- Dom Henrique Research Centre, Porto, Portugal.,Clínica Do Dragão, Espregueira-Mendes Sports Centre, FIFA Medical Centre of Excellence, Porto, Portugal.,Faculty of Sports of Porto University, Porto, Portugal
| | - Paulo Flores
- Mechanical Engineering Department, CMEMS Center for MicroElectroMechanical Systems, University of Minho, Guimarães, Portugal
| | - Filipe S Silva
- Mechanical Engineering Department, CMEMS Center for MicroElectroMechanical Systems, University of Minho, Guimarães, Portugal
| | - John Fulkerson
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Philippe Neyret
- Department of Orthopaedic Surgery, Centre Albert-Trillat, Hôpital de La Croix-Rousse, Lyon, France
| | - Elizabeth Arendt
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - João Espregueira-Mendes
- Dom Henrique Research Centre, Porto, Portugal. .,Clínica Do Dragão, Espregueira-Mendes Sports Centre, FIFA Medical Centre of Excellence, Porto, Portugal. .,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal. .,School of Medicine, Minho University, Braga, Portugal.
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Morrical BD, Dearani JA, Bonnichsen CR, Taggart NW. Exercise Capacity After Repair of Ebstein Anomaly in Adults. Pediatr Cardiol 2019; 40:726-732. [PMID: 30701277 DOI: 10.1007/s00246-019-02056-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 06/25/2018] [Accepted: 01/16/2019] [Indexed: 11/27/2022]
Abstract
Repair of Ebstein anomaly has evolved over the last decade, and timing of repair remains variable. There have been no studies of exercise or functional capacity in patients who have had tricuspid valve surgery for Ebstein anomaly in adulthood. We aimed to compare exercise capacity before and after tricuspid valve repair or replacement for Ebstein anomaly in adults at Mayo Clinic. We performed a retrospective chart review of all patients with Ebstein anomaly who underwent tricuspid valve surgery at Mayo Clinic between June 2007 and January 2015. We compared pre- and postoperative echocardiograms, exercise tests, and clinic visits. Tricuspid valve surgery was done for 322 patients, and 32 patients met criteria of native tricuspid valve repair or replacement at age 18 or older and had maximal pre- and postoperative exercise tests. Nineteen patients had valve repair, and 13 had valve replacement. Surgery for Ebstein anomaly resulted in significant reduction in tricuspid regurgitation and right ventricular size. There was a significant improvement in NYHA functional class after surgery; however, there was no significant improvement in functional aerobic capacity (FAC), metabolic equivalents (METs), exercise time, or [Formula: see text] after surgery. Patients who had an atrial shunt closed during surgery had improved minimum blood oxygen saturations during exercise, though no improvement in exercise capacity. In our cohort, patients who had tricuspid valve repair or replacement for Ebstein anomaly reported an improvement in functional capacity; however, this did not reflect improvement in measured exercise capacity, despite excellent surgical results by echocardiography.
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Affiliation(s)
- Brandon D Morrical
- Department of Pediatric Cardiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Crystal R Bonnichsen
- Divsion of Cardiology, Department of Adult Congenital Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Nathaniel W Taggart
- Department of Pediatric Cardiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
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Rakibe U, Tiwari R, Mahajan A, Rane V, Wakte P. LC and LC-MS/MS studies for the identification and characterization of degradation products of acebutolol. J Pharm Anal 2019; 8:357-365. [PMID: 30595941 PMCID: PMC6308026 DOI: 10.1016/j.jpha.2018.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 05/13/2017] [Revised: 02/11/2018] [Accepted: 03/15/2018] [Indexed: 10/27/2022] Open
Abstract
The aim of the present investigation was to demonstrate an approach involving use of liquid chromatography (LC) and liquid chromatography-mass spectrometry (LC-MS) to separate, identify and characterize very small quantities of degradation products (DPs) of acebutolol without their isolation from the reaction mixtures. The drug was subjected to oxidative, hydrolytic, thermal and photolytic stress conditions as per International Conference on Harmonization (ICH) guideline Q1A(R2). Among all the stress conditions the drug was found to be labile in hydrolytic (acidic & basic) and photolytic stress conditions, while it was stable in water-induced hydrolysis, oxidative and thermal stress conditions. A total of four degradation products were formed. A C18 column was employed for the separation of all the DPs on a gradient mode by using high-performance liquid chromatography (HPLC). All the DPs were characterized with the help of their fragmentation pattern and the masses obtained upon LC-MS/MS and MSn analysis. All the hitherto unknown degradation products were identified as 1-(2-(2-hydroxy-3-(isopropylamino)propoxy)-5-(amino)phenyl)ethanone (DP-I), N-(4-(2-hydroxy-3-(isopropylamino)propoxy)-3-acetylphenyl)acrylamide (DP-II), 1-(2-(2-hydroxy-3-(isopropylamino)propoxy)-5-(hydroxymethylamino)phenyl)ethanone (DP-III) and 1-(6-(2-hydroxy-3-(isopropylamino)propoxy)-2,3-dihydro-2-propylbenzo[d]oxazol-5-yl)ethanone (DP-IV). Finally the in-silico carcinogenicity and hepatotoxicity predictions of the drug and all the DPs were performed by using toxicity prediction softwares viz., TOPKAT, LAZAR and Discovery Studio ADMET. The results of in-silico toxicity studies revealed that acebutolol (0.967) and DP-I (0.986) were found to be carcinogenic, while acebutolol (0.490) and DP-IV (0.437) were found to be hepatotoxic.
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Affiliation(s)
- Uday Rakibe
- Department of Chemical Technology, Dr. Babasaheb Ambedkar Marathwada University, Aurangabad, Maharashtra, India
| | - Ravi Tiwari
- Department of Pharmaceutical Sciences, SVKM's NMIMS, Shirpur, Dist. Dhule, Maharashtra, India
| | - Anand Mahajan
- Department of Pharmaceutical Analysis, Goa College of Pharmacy, Panjim, Goa, India
| | - Vipul Rane
- Department of Chemical Technology, Dr. Babasaheb Ambedkar Marathwada University, Aurangabad, Maharashtra, India
| | - Pravin Wakte
- Department of Chemical Technology, Dr. Babasaheb Ambedkar Marathwada University, Aurangabad, Maharashtra, India
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Stacey RB, Vera T, Morgan TM, Jordan JH, Whitlock MC, Hall ME, Vasu S, Hamilton C, Kitzman DW, Hundley WG. Asymptomatic myocardial ischemia forecasts adverse events in cardiovascular magnetic resonance dobutamine stress testing of high-risk middle-aged and elderly individuals. J Cardiovasc Magn Reson 2018; 20:75. [PMID: 30463565 PMCID: PMC6249873 DOI: 10.1186/s12968-018-0492-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 03/02/2018] [Accepted: 10/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current guidelines for assessing the risk of experiencing a hospitalized cardiovascular (CV) event discourage stress testing of asymptomatic individuals; however, these recommendations are based on evidence gathered primarily from those aged < 60 years, and do not address the possibility of unrecognized "silent myocardial ischemia" in middle aged and older adults. METHODS We performed dobutamine cardiovascular magnetic resonance (CMR) stress testing in 327 consecutively recruited participants aged > 55 years without CV-related symptoms nor known coronary artery disease, but otherwise at increased risk for a future CV event due to pre-existing hypertension or diabetes mellitus for at least 5 years. After adjusting for the demographics and CV risk factors, log-rank test and Cox proportional hazards models determined the additional predictive value of the stress test results for forecasting hospitalized CV events/survival. Either stress-induced LV wall motion abnormalities or perfusion defects were used to indicate myocardial ischemia. RESULTS Participants averaged 68 ± 8 years in age; 39% men, 75% Caucasian. There were 38 hospitalized CV events or deaths which occurred during a mean follow-up of 58 months. Using Kaplan-Meier analyses, myocardial ischemia identified future CV events/survival (p < 0.001), but this finding was more evident in men (p < 0.001) versus women (p = 0.27). The crude hazard ratio (HR) of myocardial ischemia for CV events/survival was 3.13 (95% CI: 1.64-5.93; p < 0.001). After accounting for baseline demographics, CV risk factors, and left ventricular ejection fraction/mass, myocardial ischemia continued to be associated with CV events/survival [HR: 4.07 (95% CI: 1.95-8.73) p < 0.001]. CONCLUSIONS Among asymptomatic middle-aged individuals with risk factors for a sentinel CV event, the presence of myocardial ischemia during dobutamine CMR testing forecasted a future hospitalized CV event or death. Further studies are needed in middle aged and older individuals to more accurately characterize the prevalence, significance, and management of asymptomatic myocardial ischemia. TRIAL REGISTRATION ( ClinicalTrials.gov identifier): NCT00542503 and was retrospectively registered on October 11th, 2007.
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Affiliation(s)
- R. Brandon Stacey
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Trinity Vera
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Timothy M. Morgan
- Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Jennifer H. Jordan
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Matthew C. Whitlock
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, Palo Alto, CA USA
| | - Michael E. Hall
- Department of Medicine (Cardiovascular Medicine), University of Mississippi Medical Center, Jackson, MS USA
| | - Sujethra Vasu
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - Craig Hamilton
- Department of Radiology (Division of Radiologic Sciences), Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Dalane W. Kitzman
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
| | - W. Gregory Hundley
- Department of Internal Medicine, Cardiovascular Medicine Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 USA
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Sengupta P, Chatterjee B, Tekade RK. Current regulatory requirements and practical approaches for stability analysis of pharmaceutical products: A comprehensive review. Int J Pharm 2018; 543:328-344. [PMID: 29635054 DOI: 10.1016/j.ijpharm.2018.04.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [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] [Received: 02/21/2018] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 11/20/2022]
Abstract
Different regulatory guidelines recommend establishing stability profile of pharmaceuticals at the time of drug development. The expiry date, retesting period and storage conditions of active drugs or products are established through stability analysis. Several regulatory guidelines exist for stability testing of pharmaceuticals. Mostly, ICH stability guidelines are followed in practice. This guideline recommends to validate stability indicating method using forced degradation samples that contains all possible degradation impurities. ICH guidelines provide general recommendations for inclusion of stability indicating parameters in a stability testing protocol. However, those guidelines do not provide specific requirements and experimental methodology to be followed for stability studies. Due to this gap, often confusion arises in the scientific community in designing stability testing protocol. Therefore, significant variations are observed in reported literature in selection of stability indicating parameters. Procedural dissimilarity amongst reported stability studies is also evident. This review discusses the regulatory guidelines and procedures to follow in performing stability testing of pharmaceuticals. Scope of this review also includes recommendations on practical approaches for designing stability testing protocol to fulfill current regulatory requirements for drug substances and their formulations.
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Affiliation(s)
- Pinaki Sengupta
- National Institute of Pharmaceutical Education and Research (NIPER) - Ahmedabad, Gujarat, India.
| | - Bappaditya Chatterjee
- Department of Pharmaceutical Technology, International Islamic University Malaysia, Malaysia
| | - Rakesh Kumar Tekade
- National Institute of Pharmaceutical Education and Research (NIPER) - Ahmedabad, Gujarat, India
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van Heugten AJP, de Boer W, de Vries WS, Markesteijn CMA, Vromans H. Development and validation of a stability-indicating HPLC-UV method for the determination of triamcinolone acetonide and its degradation products in an ointment formulation. J Pharm Biomed Anal 2018; 149:265-270. [PMID: 29127908 DOI: 10.1016/j.jpba.2017.11.026] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/20/2017] [Accepted: 11/07/2017] [Indexed: 10/18/2022]
Abstract
A stability indicating high performance liquid chromatography method has been developed for the determination of triamcinolone acetonide (TCA) and its main degradation products in ointment formulations. The method, based on extensive stress testing using metal salts, azobisisobutyronitrile, acid, base and peroxide, showed that TCA undergoes oxidative degradation. All degradation products were identified using HPLC mass spectrometry. Separation and quantification was achieved using an Altima C18 RP18 HP column (250×4.6mm2, with 5μm particles) using a mobile phase consisting of acetonitrile and water buffered at pH 7 using 10mM phosphate buffer. A gradient mode was operated at a flow rate of 1.5ml/min and detection was at 241nm. The method showed linearity for TCA and Impurity C in 0.02-125% of the workload, both square roots of the correlation coefficients were larger than 0.9999. Repeatability and intermediate precision were performed by six consecutive injections of both 1.25% and 125% of the work load for both TCA and Impurity C divided equally over two days. RSD were 0.6% and 0.7% for TCA and 0.5% and 0.1% for Impurity C respectively. Accuracy was determined as well, the average recoveries were 99.5% (±0.1%, n=3) for TCA and 96.9% (±1.3%, n=3) for impurity C respectively from spiked ointment samples. The robustness was also evaluated by variations of column (old vs new), mobile phase pH and filter retention. The applicability of the method was evaluated by analysis of a commercial ointment formulation. Interestingly, the extensive stress tests were able to predict all degradation products of TCA in a long term stability ointment sample.
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Affiliation(s)
- A J P van Heugten
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, 3584 CG Utrecht, The Netherlands; Research and Development Department, Tiofarma B.V., Hermanus Boerhaavestraat 1, 3261 ME Oud-Beijerland, The Netherlands.
| | - W de Boer
- Research and Development Department, Tiofarma B.V., Hermanus Boerhaavestraat 1, 3261 ME Oud-Beijerland, The Netherlands
| | - W S de Vries
- Research and Development Department, Tiofarma B.V., Hermanus Boerhaavestraat 1, 3261 ME Oud-Beijerland, The Netherlands
| | - C M A Markesteijn
- Research and Development Department, Tiofarma B.V., Hermanus Boerhaavestraat 1, 3261 ME Oud-Beijerland, The Netherlands
| | - H Vromans
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, 3584 CG Utrecht, The Netherlands; Research and Development Department, Tiofarma B.V., Hermanus Boerhaavestraat 1, 3261 ME Oud-Beijerland, The Netherlands; Department of Clinical Pharmacy, Division of Laboratory Medicine & Pharmacy, University Medical Centre Utrecht, P/O Box 85500, 3508 GA Utrecht, The Netherlands
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48
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Kurmi M, Singh S. Stability behavior of antiretroviral drugs and their combinations. 7: Comparative degradation pathways of lamivudine and emtricitabine and explanation to their differential degradation behavior by density functional theory. J Pharm Biomed Anal 2017; 142:155-161. [PMID: 28511058 DOI: 10.1016/j.jpba.2017.04.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 03/08/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
Abstract
The interest in this study was to establish comparative degradation behavior of lamivudine (3TC) and emtricitabine (FTC) under solution and solid state stress conditions. Structurally, the two drugs differ only in terms of additional fluorine at 5 position in FTC. Along with the known degradation products of both the drugs, one additional degradation product was observed in each case, which was characterized by mass spectrometry. Both the drugs degraded via the same route, but at a differential rate in acid, base and oxidative stress conditions. The variable rate of degradation in acid and base conditions was justified by the application of density functional theory (DFT).
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Affiliation(s)
- Moolchand Kurmi
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S.A.S., Nagar 160 062, Punjab, India
| | - Saranjit Singh
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S.A.S., Nagar 160 062, Punjab, India.
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Bomb R, Kumar S, Chockalingam A. Coronary artery disease detection - limitations of stress testing in left ventricular dysfunction. World J Cardiol 2017; 9:304-311. [PMID: 28515848 PMCID: PMC5411964 DOI: 10.4330/wjc.v9.i4.304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/12/2016] [Accepted: 02/13/2017] [Indexed: 02/06/2023] Open
Abstract
Incidental diagnosis of left ventricular systolic dysfunction (LVD) is common in clinical practice. The prevalence of asymptomatic LVD (Ejection Fraction, EF < 50%) is 6.0% in men and 0.8% in women and is twice as common as symptomatic LVD. The timely and definitive exclusion of an ischemic etiology is central to optimizing care and reducing mortality in LVD. Advances in cardiovascular imaging provide many options for imaging of patients with left ventricular dysfunction. Clinician experience, patient endurance, imaging modality characteristics, cost and safety determine the choice of testing. In this review, we have compared the diagnostic utility of established tests - nuclear and echocardiographic stress testing with newer techniques like coronary computerized tomography and cardiac magnetic resonance imaging and highlight their inherent limitations in patients with underlying left ventricular dysfunction.
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50
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Bird JG, McCully RB, Pellikka PA, Kane GC. Dobutamine Stress Echocardiography: Impact of Abnormal Blood Potassium Levels on Cardiac Arrhythmias. J Am Soc Echocardiogr 2017; 30:595-601. [PMID: 28395912 DOI: 10.1016/j.echo.2017.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 12/13/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Guidelines suggest that an abnormal blood potassium level is a relative contraindication to performing dobutamine stress echocardiography (DSE). However, this has not been previously studied. METHODS We reviewed a consecutive series of patients who had potassium testing within 48 hours of undergoing DSE for the evaluation of myocardial ischemia over a 10-year period (N = 13,198). Normal potassium range in our laboratory is 3.6-5.2 mmol/L. Hemolyzed samples were not included. The association of potassium levels with the development of supraventricular and ventricular arrhythmias was assessed. RESULTS The incidence of clinically significant arrhythmias was very low (supraventricular tachycardia/atrial fibrillation, 4.9%; nonsustained ventricular tachycardia, 2.9%; sustained ventricular tachycardia or ventricular fibrillation, 0.1%), confirming the overall safety of DSE. Most arrhythmias (88%) occurred in patients with normal potassium levels, and arrhythmia rates remained low in patients with potassium abnormalities. Patients with hyperkalemia had a lower risk of developing mild (odds ratio [OR], 0.39; 95% CI, 0.22-0.71) and severe (OR, 0.13; 95% CI, 0.01-0.68) supraventricular arrhythmias as well as mild ventricular arrhythmias (OR, 0.58; 95% CI, 0.40-0.83). Even though events were rare, patients with severe hypokalemia (potassium levels ≤ 3.1 mmol/L) had an increased risk of supraventricular arrhythmia and ventricular ectopy. CONCLUSIONS DSE is safe even in the setting of abnormalities in blood potassium concentrations, and hence cancellation of DSE in patients with potassium abnormalities does not appear warranted. Elevated potassium levels are associated with lower rates of clinically significant supraventricular and ventricular arrhythmias. While remaining at relatively low risk, patients with very low potassium levels (≤3.1 mmol/L) at the time of DSE have a modestly increased risk of arrhythmia. Consideration could be given to correcting severe hypokalemia prior to DSE.
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Affiliation(s)
- Jared G Bird
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Robert B McCully
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Patricia A Pellikka
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
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