This study investigated the relationship between chest pain during radionuclide myocardial perfusion imaging and stress modality (exercise vs. dipyridamole) and imaging findings. The study included 100 patients undergoing imaging, with 50 undergoing exercise stress and 50 undergoing dipyridamole stress. Exercise was found to cause more chest pain and ECG changes than dipyridamole. Chest pain severity correlated with number of affected vessel territories for dipyridamole but not exercise. The study developed a new 9-point score based on parameters during imaging to predict degree of perfusion defects seen, with higher scores correlating with more defects.
Study of Cardiac Morbidities in Critically Ill Patients Admitted to Intensive...Premier Publishers
This study was conducted in cooperation between Al-Azhar university and El-Haram specialized hospital in Cairo - Egypt during the period between November 2015 and November 2016 to detect and assess the new cardiovascular adverse events that happened to critically ill patients during their admission in intensive care unit, the commonest complications happened was Venous-Thrombo-Embolism and Atrial Fibrillation. This study focused on the etiology, incidence and management of cardiovascular adverse events. The objective of this study was to evaluate the type and outcomes of cardiovascular complications in patients admitted to intensive care unit (ICU) due to non-cardiac causes.
Papua New Guinea has about seven active mining and exploration activities for minerals like gold, copper, and other minor minerals. Each is managed by different company and
together employs about ten thousand workers. A fifth of this would be foreign workers. Most of the Mine workers that are screened at the Employees Health and Wellness clinics tend to
have similar compounding health risks
The Effect of Long Term Smoking as an Independent Coronary Risk
Factor on Myocardial Perfusion Detected by Thallium 201 or Tc99m Sestamibi Spect Study. Samir Rafla*, Ahmed Ibrahim Abdel-Aaty, Mohammed Ibrahim Lotfy and Riham Gamal
Achieving Blood Pressure Goal: From Clinical Trial into Real-World DataSuharti Wairagya
Hypertension remains a major global health issue, with over 7 million deaths annually associated with it. Less than 50% of hypertensive patients receive therapy, and approximately 70% of treated patients do not reach blood pressure goals. Most guidelines recommend initiating treatment with two drugs when blood pressure is more than 20/10 mmHg above goal or for those at high cardiovascular risk. Clinical trials have shown that the amlodipine/valsartan combination effectively lowers blood pressure and helps more patients achieve goals compared to monotherapy. Real-world Indonesian studies found that amlodipine/valsartan combination therapy was effective at controlling blood pressure in the majority of uncontrolled hypertensive patients switched from monotherapy.
This study compared long-term outcomes of patients who underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for lesions located in the proximal left anterior descending (LAD) artery versus nonproximal LAD lesions. The study analyzed data from 8,709 patients in the PROTECT trial. Results showed no significant differences in rates of death, major adverse cardiac events (MACE), or target vessel failure at 4 years between patients treated for proximal versus nonproximal LAD lesions. Treatment of lesions in the proximal LAD, which supplies a large portion of the left ventricle, did not appear to influence long-term outcomes with modern DES and medical therapy.
1) The EAST-AFNET trial compared an early rhythm control strategy to usual care for patients with recent-onset atrial fibrillation.
2) The early rhythm control strategy involved early use of antiarrhythmic drugs or ablation to maintain sinus rhythm, while usual care followed guidelines.
3) The trial was stopped early as early rhythm control reduced the composite outcome of death, stroke, or hospitalization compared to usual care over 5 years of follow-up.
Background and Aim: Many studies have found association between Red Cell Distribution Width (RDW) values and hypertension, dipping pattern, and end-organ damage. RDW values are affected by blood vitamin B12, iron, and folic acid levels, parameters that were not assessed in the previous studies. The aim of our study was to evaluate the relation between RDW and hypertension, dipper pattern, and end-organ damage independently from vitamin B12, folic acid, and ferritin levels in newly diagnosed hypertensive patients.
1. Three key elements must be assessed to determine a patient's surgical risk: underlying medical conditions and diseases, functional status, and type of surgery.
2. The American Society of Anesthesiologists (ASA) Physical Status classification is commonly used but is limited in only considering medical history and does not include other factors like surgery type. Higher ASA classes correlate with increased postoperative complications and mortality.
3. Other tools like the Goldman Cardiac Risk Index and Revised Cardiac Risk Index were developed to better evaluate cardiac risk, but have limitations and may not predict all-cause mortality risk.
Study of Cardiac Morbidities in Critically Ill Patients Admitted to Intensive...Premier Publishers
This study was conducted in cooperation between Al-Azhar university and El-Haram specialized hospital in Cairo - Egypt during the period between November 2015 and November 2016 to detect and assess the new cardiovascular adverse events that happened to critically ill patients during their admission in intensive care unit, the commonest complications happened was Venous-Thrombo-Embolism and Atrial Fibrillation. This study focused on the etiology, incidence and management of cardiovascular adverse events. The objective of this study was to evaluate the type and outcomes of cardiovascular complications in patients admitted to intensive care unit (ICU) due to non-cardiac causes.
Papua New Guinea has about seven active mining and exploration activities for minerals like gold, copper, and other minor minerals. Each is managed by different company and
together employs about ten thousand workers. A fifth of this would be foreign workers. Most of the Mine workers that are screened at the Employees Health and Wellness clinics tend to
have similar compounding health risks
The Effect of Long Term Smoking as an Independent Coronary Risk
Factor on Myocardial Perfusion Detected by Thallium 201 or Tc99m Sestamibi Spect Study. Samir Rafla*, Ahmed Ibrahim Abdel-Aaty, Mohammed Ibrahim Lotfy and Riham Gamal
Achieving Blood Pressure Goal: From Clinical Trial into Real-World DataSuharti Wairagya
Hypertension remains a major global health issue, with over 7 million deaths annually associated with it. Less than 50% of hypertensive patients receive therapy, and approximately 70% of treated patients do not reach blood pressure goals. Most guidelines recommend initiating treatment with two drugs when blood pressure is more than 20/10 mmHg above goal or for those at high cardiovascular risk. Clinical trials have shown that the amlodipine/valsartan combination effectively lowers blood pressure and helps more patients achieve goals compared to monotherapy. Real-world Indonesian studies found that amlodipine/valsartan combination therapy was effective at controlling blood pressure in the majority of uncontrolled hypertensive patients switched from monotherapy.
This study compared long-term outcomes of patients who underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for lesions located in the proximal left anterior descending (LAD) artery versus nonproximal LAD lesions. The study analyzed data from 8,709 patients in the PROTECT trial. Results showed no significant differences in rates of death, major adverse cardiac events (MACE), or target vessel failure at 4 years between patients treated for proximal versus nonproximal LAD lesions. Treatment of lesions in the proximal LAD, which supplies a large portion of the left ventricle, did not appear to influence long-term outcomes with modern DES and medical therapy.
1) The EAST-AFNET trial compared an early rhythm control strategy to usual care for patients with recent-onset atrial fibrillation.
2) The early rhythm control strategy involved early use of antiarrhythmic drugs or ablation to maintain sinus rhythm, while usual care followed guidelines.
3) The trial was stopped early as early rhythm control reduced the composite outcome of death, stroke, or hospitalization compared to usual care over 5 years of follow-up.
Background and Aim: Many studies have found association between Red Cell Distribution Width (RDW) values and hypertension, dipping pattern, and end-organ damage. RDW values are affected by blood vitamin B12, iron, and folic acid levels, parameters that were not assessed in the previous studies. The aim of our study was to evaluate the relation between RDW and hypertension, dipper pattern, and end-organ damage independently from vitamin B12, folic acid, and ferritin levels in newly diagnosed hypertensive patients.
1. Three key elements must be assessed to determine a patient's surgical risk: underlying medical conditions and diseases, functional status, and type of surgery.
2. The American Society of Anesthesiologists (ASA) Physical Status classification is commonly used but is limited in only considering medical history and does not include other factors like surgery type. Higher ASA classes correlate with increased postoperative complications and mortality.
3. Other tools like the Goldman Cardiac Risk Index and Revised Cardiac Risk Index were developed to better evaluate cardiac risk, but have limitations and may not predict all-cause mortality risk.
1. Aspirin use resulted in a 12% lower risk of serious vascular events but also a 29% higher risk of major bleeding in patients with diabetes but no cardiovascular disease. The benefits of aspirin for vascular events were similar to the risks of major bleeding.
2. There was no significant effect of aspirin on cancer risk or microvascular outcomes. No differences emerged even with long-term follow-up.
3. The risks and benefits of low-dose aspirin were closely balanced in patients with diabetes but no cardiovascular disease. Routine aspirin use cannot be recommended for primary prevention in this population.
This document reviews the management of hypertensive emergencies associated with aortic dissection and thoracic aortic aneurysms. It discusses that immediate control of blood pressure is critical for these conditions to prevent further damage. For aortic dissections, surgery is usually recommended for Type A dissections while medical therapy is preferred for Type B dissections. The goals of treatment are to relieve symptoms, reduce complications, and prevent rupture. Several antihypertensive drugs are discussed for rapidly lowering blood pressure in hypertensive emergencies associated with these aortic conditions. Outcomes have improved but morbidity and mortality remain high, posing a significant treatment challenge.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
This Journal publishes original research work that contributes significantly to further the scientific knowledge in pharmacy.
Role of Left Ventricular Mass Index Versus Left Ventricular Relative Wall Thi...Premier Publishers
This study examined left ventricular geometry in 100 patients with non-cardioembolic ischemic stroke using echocardiography. The study found that concentric remodeling was the most common left ventricular pattern at 43%, followed by normal geometry at 27%, concentric hypertrophy at 22%, and eccentric hypertrophy at 8%. Abnormal left ventricular relative wall thickness was more common than abnormal left ventricular mass index, occurring in 61.4% versus 38.6% of patients. The results suggest that assessing relative wall thickness in addition to mass index can help identify more patients with left ventricular remodeling who may be at increased risk of stroke.
1) The study examined predictors of ischemia and outcomes in 169 Egyptian patients with diabetes referred for nuclear perfusion imaging over 2 years of follow up.
2) Significant relationships were found between higher summed stress scores and outcomes of sudden cardiac death, myocardial infarction, and heart failure. Higher summed rest scores also significantly predicted several adverse outcomes.
3) Degree of typical chest pain, transient left ventricular dilation, lung uptake on imaging, and extent of ischemia (summed difference score) were independent predictors of myocardial infarction. Transient left ventricular dilation was the strongest predictor of sudden cardiac death.
1) Atrial fibrillation increases the risk of stroke by 5 times and warfarin has been shown to significantly reduce this risk by 62% according to clinical trials.
2) However, warfarin is still underused in clinical practice due to concerns about risks of bleeding, particularly in elderly patients.
3) Maintaining an international normalized ratio between 2.0-3.0 provides optimal stroke reduction with minimal bleeding risk, though risk increases above 4.0.
Translational Updates in HF: Evolving Science for the Practicing ClinicianDuke Heart
This document discusses recent translational updates in heart failure (HF) for clinicians. It begins by defining pulmonary hypertension (PH) and its subtypes. It then reviews current PAH therapies and recent clinical trials. Precision medicine approaches in PAH are also discussed. A phase 2 trial of the drug sotatercept in PAH is summarized, which aims to treat PAH by targeting transforming growth factor-beta signaling. The document concludes by noting treatment of PH is guided by diagnosis and current PAH treatment focuses on combination therapy and achieving low risk status, while challenges include treating non-Group 1 PH and patients who change PH groups.
lung ultrasound , ambulatory blood pressure monitoring Amr Albitar
This document is the thesis submitted by Amr Refay Albitar to the Faculty of Medicine at Cairo University in partial fulfillment of an MSc degree in Internal Medicine. The thesis aims to study ambulatory blood pressure monitoring and lung ultrasound as new predictors of cardiovascular morbidity in end stage renal disease patients. It includes an introduction, aim of work, materials and methods, results, discussion, conclusion, and recommendations sections. The materials and methods section describes how the study included 50 end stage renal disease patients on hemodialysis divided into two groups based on interdialytic weight gain and were subjected to medical history, exams, tests including ambulatory blood pressure monitoring and lung ultrasound.
técnicas de reparación de una hernia, ... bien al paciente para elegir la técnica ... La reparación clásica de la hernia umbilical es la hernioplastia de Mayo, que
Rivaroxaban for thromboprophylaxis after Hospitalization for Medical IllnessShadab Ahmad
Anticoagulant prophylaxis reduces the risk of in-hospital venous thromboembolism by 50 to 60% but is rarely continued after discharge in accordance with current guidelines
Urocortin-2 Infusion in Acute Decompensated Heart Failure
The study investigated the effects of urocortin-2 infusion compared to placebo in patients with acute decompensated heart failure. Fifty-three patients were randomly assigned to receive either 5 ng/kg/min of urocortin-2 or placebo infusion for 4 hours in addition to standard therapy. Urocortin-2 produced greater increases in cardiac output and decreases in blood pressure and total peripheral resistance compared to placebo. Renal indices fell transiently during urocortin-2 infusion but returned to above baseline levels after infusion. Further studies are needed to understand the full potential of urocortin-2 for treating acute
This document summarizes a literature review on thromboprophylaxis in intensive care unit (ICU) patients. It was published on September 21, 2018 after being reviewed from September 7-9, 2018. The review discusses the epidemiology and risk factors of thromboembolism in ICU patients. It also examines the challenges of diagnosing deep vein thrombosis and pulmonary embolism in critically ill patients. Finally, it analyzes the existing evidence on pharmacological thromboprophylaxis using heparins as well as mechanical thromboprophylaxis for high-bleeding risk ICU patients.
1. Recurrent myocardial infarction (MI) after primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) occurs in about 21% of patients and is associated with worse clinical outcomes.
2. Recurrent MI significantly increases the risks of subsequent cardiac mortality, noncardiac mortality, stroke, and bleeding.
3. Early recurrent MIs within 1 day of the initial PPCI are associated with higher unadjusted cardiac mortality compared to later recurrent MIs, but after adjustment, recurrent MIs occurring more than 1 year after PPCI carry the highest risk of cardiac death.
Outcome After Procedures for Retained Blood Syndrome in Coronary SurgeryPaul Molloy
OBJECTIVES:
Incomplete drainage of blood from around the heart and lungs can lead to retained blood syndrome (RBS) after cardiac sur-
gery. The aim of this study was to assess the incidence of and the outcome after procedures for RBS in patients undergoing isolated coronary artery bypass grafting (CABG)-
This study retrospectively compared clinical outcomes of patients hospitalized for gastrointestinal bleeding while taking dabigatran versus warfarin. Thirteen patients on dabigatran were compared to 26 patients on warfarin. Patients in both groups had similar demographic characteristics and medical histories. Patients taking warfarin received significantly more packed red blood cell transfusions compared to those taking dabigatran. However, clinical outcomes like length of stay and rates of hypotension or death were comparable between the two groups. This study analyzed an elderly population with creatinine clearance over 30 mL/min experiencing GI bleeding while anticoagulated.
The document provides guidelines for perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. It was developed by an expert panel representing multiple medical societies. The guidelines include recommendations on preoperative risk assessment, management of valvular heart disease and pulmonary hypertension, use of cardiovascular implantable electronic devices, and approaches to predicting and reducing perioperative cardiac risk. A stepwise approach to preoperative cardiac assessment and management is presented based on urgency of surgery and estimated risk of major adverse cardiac events.
Background: Myocarditis is a relatively common inflammatory disease that affects the myocardium. Infectious disease accounts for most of the cases either because of a direct viral infection or post-viral immune-mediated reaction. Cardiovascular magnetic resonance (CMR) has become an established non-invasive diagnosis tool for acute myocarditis. A recent large single centre study with patients with biopsy-proven viral myocarditis undergoing CMR scans found a high rate of mortality. The aim of this study was to assess the rate of clinical events in our population of patients with diagnosed myocarditis by CMR scan.
Methods: Patients who consulted to the emergency department with diagnosis of myocarditis by CMR were retrospectively included in the study from January 2008 to May 2012. A CMR protocol was used in all patients, and were followed up to assess the rate of the composite endpoint of all-cause death, congestive heart failure, sudden cardiac death, hospitalization for cardiac cause, recurrent myocarditis or need of radiofrequency ablation or implantable cardiac defibrillator (ICD). A descriptive statistical analysis was performed.
Results: Thirty-two patients with myocarditis were included in the study. The mean age was 42.6±21.2 years and 81.2% were male. In a mean follow up of 30.4±17.8 months, the rate of the composite endpoint of all-cause death, congestive heart failure, sudden cardiac death, hospitalization for cardiac cause, recurrent myocarditis or need of radiofrequency ablation or ICD was 15.6% (n=5). Two patients had heart failure (one of them underwent heart transplant), one patient needed ICD because of ventricular tachycardia and two other patients were re-hospitalized, for recurrent chest pain and for recurrent myocarditis respectively.
Conclusions: In our series of acute myocarditis diagnosed by CMR we found a low rate of cardiovascular events without mortality. These findings might oppose data from recently published myocarditis trials.
Important Clinical Trials In Cardiology - An Overview 2016-17Amit Verma
A randomized clinical trial compared outcomes of 885 patients with STEMI and multivessel disease who underwent primary PCI of an infarct artery and were then randomly assigned to either complete revascularization of additional arteries guided by FFR (fractional flow reserve) or no further intervention. The primary composite outcome of death, MI, revascularization or stroke occurred in 8% of those who received complete revascularization versus 21% of those who received PCI only of the infarct artery. Complete revascularization significantly reduced risk of future cardiovascular events.
The recalibrated thoracic revised cardiac risk index (ThRCRI) aims to predict cardiac risk for patients undergoing lung resection. This study externally validates the ThRCRI in 2,621 patients who underwent lobectomy or pneumonectomy. Patients were grouped into four risk classes by the ThRCRI. The incidence of major cardiac complications increased from 0.9% in the lowest risk class to 18% in the highest risk class, demonstrating the ThRCRI's ability to stratify risk. Bootstrapping analysis supported the ThRCRI's reliability in predicting cardiac risk across different patient populations. The ThRCRI is a useful tool for identifying patients needing further cardiac testing before lung resection.
This document describes a clinical trial that compared the effects of a fixed-dose combination of perindopril and amlodipine on target organ damage in hypertensive patients with and without ischemic heart disease. Sixty patients were treated with escalating doses of perindopril/amlodipine for 12 months. Target organ damage measures including blood pressure, arterial stiffness, cardiac parameters, and biomarkers were assessed at baseline and during treatment. Therapy effectively lowered blood pressure and regressed target organ damage in both groups, though some measures of improvement differed between patients with and without ischemic heart disease. The study demonstrates the effectiveness of perindopril/amlodipine for treating hypertension and regressing target organ damage in patients both
1. Aspirin use resulted in a 12% lower risk of serious vascular events but also a 29% higher risk of major bleeding in patients with diabetes but no cardiovascular disease. The benefits of aspirin for vascular events were similar to the risks of major bleeding.
2. There was no significant effect of aspirin on cancer risk or microvascular outcomes. No differences emerged even with long-term follow-up.
3. The risks and benefits of low-dose aspirin were closely balanced in patients with diabetes but no cardiovascular disease. Routine aspirin use cannot be recommended for primary prevention in this population.
This document reviews the management of hypertensive emergencies associated with aortic dissection and thoracic aortic aneurysms. It discusses that immediate control of blood pressure is critical for these conditions to prevent further damage. For aortic dissections, surgery is usually recommended for Type A dissections while medical therapy is preferred for Type B dissections. The goals of treatment are to relieve symptoms, reduce complications, and prevent rupture. Several antihypertensive drugs are discussed for rapidly lowering blood pressure in hypertensive emergencies associated with these aortic conditions. Outcomes have improved but morbidity and mortality remain high, posing a significant treatment challenge.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
This Journal publishes original research work that contributes significantly to further the scientific knowledge in pharmacy.
Role of Left Ventricular Mass Index Versus Left Ventricular Relative Wall Thi...Premier Publishers
This study examined left ventricular geometry in 100 patients with non-cardioembolic ischemic stroke using echocardiography. The study found that concentric remodeling was the most common left ventricular pattern at 43%, followed by normal geometry at 27%, concentric hypertrophy at 22%, and eccentric hypertrophy at 8%. Abnormal left ventricular relative wall thickness was more common than abnormal left ventricular mass index, occurring in 61.4% versus 38.6% of patients. The results suggest that assessing relative wall thickness in addition to mass index can help identify more patients with left ventricular remodeling who may be at increased risk of stroke.
1) The study examined predictors of ischemia and outcomes in 169 Egyptian patients with diabetes referred for nuclear perfusion imaging over 2 years of follow up.
2) Significant relationships were found between higher summed stress scores and outcomes of sudden cardiac death, myocardial infarction, and heart failure. Higher summed rest scores also significantly predicted several adverse outcomes.
3) Degree of typical chest pain, transient left ventricular dilation, lung uptake on imaging, and extent of ischemia (summed difference score) were independent predictors of myocardial infarction. Transient left ventricular dilation was the strongest predictor of sudden cardiac death.
1) Atrial fibrillation increases the risk of stroke by 5 times and warfarin has been shown to significantly reduce this risk by 62% according to clinical trials.
2) However, warfarin is still underused in clinical practice due to concerns about risks of bleeding, particularly in elderly patients.
3) Maintaining an international normalized ratio between 2.0-3.0 provides optimal stroke reduction with minimal bleeding risk, though risk increases above 4.0.
Translational Updates in HF: Evolving Science for the Practicing ClinicianDuke Heart
This document discusses recent translational updates in heart failure (HF) for clinicians. It begins by defining pulmonary hypertension (PH) and its subtypes. It then reviews current PAH therapies and recent clinical trials. Precision medicine approaches in PAH are also discussed. A phase 2 trial of the drug sotatercept in PAH is summarized, which aims to treat PAH by targeting transforming growth factor-beta signaling. The document concludes by noting treatment of PH is guided by diagnosis and current PAH treatment focuses on combination therapy and achieving low risk status, while challenges include treating non-Group 1 PH and patients who change PH groups.
lung ultrasound , ambulatory blood pressure monitoring Amr Albitar
This document is the thesis submitted by Amr Refay Albitar to the Faculty of Medicine at Cairo University in partial fulfillment of an MSc degree in Internal Medicine. The thesis aims to study ambulatory blood pressure monitoring and lung ultrasound as new predictors of cardiovascular morbidity in end stage renal disease patients. It includes an introduction, aim of work, materials and methods, results, discussion, conclusion, and recommendations sections. The materials and methods section describes how the study included 50 end stage renal disease patients on hemodialysis divided into two groups based on interdialytic weight gain and were subjected to medical history, exams, tests including ambulatory blood pressure monitoring and lung ultrasound.
técnicas de reparación de una hernia, ... bien al paciente para elegir la técnica ... La reparación clásica de la hernia umbilical es la hernioplastia de Mayo, que
Rivaroxaban for thromboprophylaxis after Hospitalization for Medical IllnessShadab Ahmad
Anticoagulant prophylaxis reduces the risk of in-hospital venous thromboembolism by 50 to 60% but is rarely continued after discharge in accordance with current guidelines
Urocortin-2 Infusion in Acute Decompensated Heart Failure
The study investigated the effects of urocortin-2 infusion compared to placebo in patients with acute decompensated heart failure. Fifty-three patients were randomly assigned to receive either 5 ng/kg/min of urocortin-2 or placebo infusion for 4 hours in addition to standard therapy. Urocortin-2 produced greater increases in cardiac output and decreases in blood pressure and total peripheral resistance compared to placebo. Renal indices fell transiently during urocortin-2 infusion but returned to above baseline levels after infusion. Further studies are needed to understand the full potential of urocortin-2 for treating acute
This document summarizes a literature review on thromboprophylaxis in intensive care unit (ICU) patients. It was published on September 21, 2018 after being reviewed from September 7-9, 2018. The review discusses the epidemiology and risk factors of thromboembolism in ICU patients. It also examines the challenges of diagnosing deep vein thrombosis and pulmonary embolism in critically ill patients. Finally, it analyzes the existing evidence on pharmacological thromboprophylaxis using heparins as well as mechanical thromboprophylaxis for high-bleeding risk ICU patients.
1. Recurrent myocardial infarction (MI) after primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) occurs in about 21% of patients and is associated with worse clinical outcomes.
2. Recurrent MI significantly increases the risks of subsequent cardiac mortality, noncardiac mortality, stroke, and bleeding.
3. Early recurrent MIs within 1 day of the initial PPCI are associated with higher unadjusted cardiac mortality compared to later recurrent MIs, but after adjustment, recurrent MIs occurring more than 1 year after PPCI carry the highest risk of cardiac death.
Outcome After Procedures for Retained Blood Syndrome in Coronary SurgeryPaul Molloy
OBJECTIVES:
Incomplete drainage of blood from around the heart and lungs can lead to retained blood syndrome (RBS) after cardiac sur-
gery. The aim of this study was to assess the incidence of and the outcome after procedures for RBS in patients undergoing isolated coronary artery bypass grafting (CABG)-
This study retrospectively compared clinical outcomes of patients hospitalized for gastrointestinal bleeding while taking dabigatran versus warfarin. Thirteen patients on dabigatran were compared to 26 patients on warfarin. Patients in both groups had similar demographic characteristics and medical histories. Patients taking warfarin received significantly more packed red blood cell transfusions compared to those taking dabigatran. However, clinical outcomes like length of stay and rates of hypotension or death were comparable between the two groups. This study analyzed an elderly population with creatinine clearance over 30 mL/min experiencing GI bleeding while anticoagulated.
The document provides guidelines for perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. It was developed by an expert panel representing multiple medical societies. The guidelines include recommendations on preoperative risk assessment, management of valvular heart disease and pulmonary hypertension, use of cardiovascular implantable electronic devices, and approaches to predicting and reducing perioperative cardiac risk. A stepwise approach to preoperative cardiac assessment and management is presented based on urgency of surgery and estimated risk of major adverse cardiac events.
Background: Myocarditis is a relatively common inflammatory disease that affects the myocardium. Infectious disease accounts for most of the cases either because of a direct viral infection or post-viral immune-mediated reaction. Cardiovascular magnetic resonance (CMR) has become an established non-invasive diagnosis tool for acute myocarditis. A recent large single centre study with patients with biopsy-proven viral myocarditis undergoing CMR scans found a high rate of mortality. The aim of this study was to assess the rate of clinical events in our population of patients with diagnosed myocarditis by CMR scan.
Methods: Patients who consulted to the emergency department with diagnosis of myocarditis by CMR were retrospectively included in the study from January 2008 to May 2012. A CMR protocol was used in all patients, and were followed up to assess the rate of the composite endpoint of all-cause death, congestive heart failure, sudden cardiac death, hospitalization for cardiac cause, recurrent myocarditis or need of radiofrequency ablation or implantable cardiac defibrillator (ICD). A descriptive statistical analysis was performed.
Results: Thirty-two patients with myocarditis were included in the study. The mean age was 42.6±21.2 years and 81.2% were male. In a mean follow up of 30.4±17.8 months, the rate of the composite endpoint of all-cause death, congestive heart failure, sudden cardiac death, hospitalization for cardiac cause, recurrent myocarditis or need of radiofrequency ablation or ICD was 15.6% (n=5). Two patients had heart failure (one of them underwent heart transplant), one patient needed ICD because of ventricular tachycardia and two other patients were re-hospitalized, for recurrent chest pain and for recurrent myocarditis respectively.
Conclusions: In our series of acute myocarditis diagnosed by CMR we found a low rate of cardiovascular events without mortality. These findings might oppose data from recently published myocarditis trials.
Important Clinical Trials In Cardiology - An Overview 2016-17Amit Verma
A randomized clinical trial compared outcomes of 885 patients with STEMI and multivessel disease who underwent primary PCI of an infarct artery and were then randomly assigned to either complete revascularization of additional arteries guided by FFR (fractional flow reserve) or no further intervention. The primary composite outcome of death, MI, revascularization or stroke occurred in 8% of those who received complete revascularization versus 21% of those who received PCI only of the infarct artery. Complete revascularization significantly reduced risk of future cardiovascular events.
The recalibrated thoracic revised cardiac risk index (ThRCRI) aims to predict cardiac risk for patients undergoing lung resection. This study externally validates the ThRCRI in 2,621 patients who underwent lobectomy or pneumonectomy. Patients were grouped into four risk classes by the ThRCRI. The incidence of major cardiac complications increased from 0.9% in the lowest risk class to 18% in the highest risk class, demonstrating the ThRCRI's ability to stratify risk. Bootstrapping analysis supported the ThRCRI's reliability in predicting cardiac risk across different patient populations. The ThRCRI is a useful tool for identifying patients needing further cardiac testing before lung resection.
This document describes a clinical trial that compared the effects of a fixed-dose combination of perindopril and amlodipine on target organ damage in hypertensive patients with and without ischemic heart disease. Sixty patients were treated with escalating doses of perindopril/amlodipine for 12 months. Target organ damage measures including blood pressure, arterial stiffness, cardiac parameters, and biomarkers were assessed at baseline and during treatment. Therapy effectively lowered blood pressure and regressed target organ damage in both groups, though some measures of improvement differed between patients with and without ischemic heart disease. The study demonstrates the effectiveness of perindopril/amlodipine for treating hypertension and regressing target organ damage in patients both
This document describes a clinical trial that compared the effects of a fixed-dose combination of perindopril and amlodipine on target organ damage in hypertensive patients with and without ischemic heart disease. Sixty patients were treated with escalating doses of perindopril/amlodipine for 12 months. Measurements of blood pressure, arterial stiffness, cardiac function, and other parameters were taken at baseline and during treatment. Therapy effectively lowered blood pressure and regressed target organ damage in both groups. However, some aspects of target organ damage regression differed between the groups.
Perspective of Cardiac Troponin and Membrane Potential in People Living with ...asclepiuspdfs
Background: Hypertension is an event in which the force of the blood against the artery walls is too high leading to severe health complications and increases the risk of heart disease, stroke, and sometimes death. Aim: This study was carried out to determine the levels of cardiac troponin 1 and membrane potential in hypertensive subjects in Owerri, Imo state. Materials and Methods: A total of 120 subjects within the age 30–70 years were recruited for this study. The study consists of 60 subjects who were diagnosed of hypertension and 60 were apparently healthy individuals who served as controls subjects of the same age bracket. The levels of cardiac troponin 1 and membrane potential were analyzed using enzyme-linked immunosorbent assay technique. Data were assessed using SPSS version 20, the mean value with P ˂ 0.05 was considered statistically significant. Results: The result revealed that the levels of cardiac troponin 1 in hypertension were significantly increased when compared with control subjects while the levels of membrane potential were significantly decreased when compared to control at P < 0.05. Conclusion: The increased serum level of cardiac troponin 1 and decreased membrane potential in hypertensive subjects may contribute some risk factors in patients with hypertension.
This study aimed to evaluate myocardial injury in children with unoperated congenital heart diseases using cardiac troponin I levels. The study found an 80% incidence of elevated cTnI levels in children with CHDs, indicating a high prevalence of myocardial injury. Univariate analysis revealed significant correlations between higher cTnI levels and hemodynamic factors like higher pulmonary to systemic blood flow and pressure ratios. The study concludes that cTnI is a useful marker for detecting myocardial injury in children with unoperated CHDs.
Safety and efficacy of Ivabradine in patients with acute ST-segment elevation...Premier Publishers
ST segment elevation myocardial infarction (STEMI) is commonly induced by thrombus formation leading to complete occlusion of a major epicardial coronary vessel. We aimed to explore safety and efficacy of Ivabradine in patients with STEMI associated with left ventricular dysfunction. 200 consecutive patients with STEMI were included in this controlled study. All patients had successful reperfusion and LVEF less than 50%. 100 patients received 5 mg ivabradine twice a day in addition to the conventional treatment, while 100 patients received the conventional treatment only. Composite end point of death, re-infarction, overt heart failure, or need for revascularization was reported at 30 days. Ivabradine when added to the conventional treatment reduced the heart rate significantly compared to the conventional treatment alone. However it did not affect incidence of primary end point. Ivabradine didn't show a significant impact on major adverse cardiac events when added to conventional treatment.
The document summarizes a journal presentation comparing the efficacy and safety of new oral anticoagulants (NOACs) to warfarin for stroke prevention in atrial fibrillation patients. It provides background on atrial fibrillation and an overview of 4 large randomized controlled trials evaluating dabigatran, rivaroxaban, apixaban, and edoxaban. A meta-analysis of these trials found NOACs reduced the risk of stroke and systemic embolism by 19% and lowered mortality compared to warfarin, while increasing gastrointestinal bleeding but decreasing intracranial hemorrhage. NOACs showed consistent benefits across patient subgroups.
This document discusses heart failure, including its increasing prevalence globally, definitions, classifications, management, and new strategies. Some key points:
- Heart failure prevalence is increasing worldwide and mortality remains high, around 50% within 5 years of diagnosis.
- The universal definition characterizes heart failure as a clinical syndrome caused by structural or functional cardiac abnormalities, accompanied by typical symptoms and signs.
- Management focuses on guideline-directed medical therapies (GDMT) including ACE inhibitors, ARBs, beta-blockers, and MRAs, though utilization remains suboptimal.
- The PARADIGM-HF trial showed the ARNI drug sacubitril/valsartan reduced cardiovascular death and heart failure
Does Type of Dialysis Affect BNP in Fluid Overload Patients?Premier Publishers
This study investigated how type of dialysis affects brain natriuretic peptide (BNP) levels in fluid overload patients. The study compared 24 hemodialysis patients and 35 peritoneal dialysis patients. It found that BNP, left ventricular mass, and left ventricular mass index levels were significantly higher in hemodialysis patients, possibly due to hemodynamic changes during hemodialysis. BNP levels correlated with left ventricular mass index in both hemodialysis and peritoneal dialysis patients. Predialysis BNP levels in hemodialysis patients were significantly higher than postdialysis levels. The type of dialysis had a significant effect on BNP levels regardless of whether patients had hypertension.
Peripheral arterial disease is a complex disease affecting
the arterial system of the lower extremities. It has a
multifactorial etiology presenting with a wide spectrum
of symptoms. Clinical examination, laboratory
evaluation and imaging are essential for accurate
assessment of the severity of the disease. Treatment is
multidisciplinary comprising medical therapy as well as
surgical intervention. The article provides a systematic
approach to assessment and treatment of peripheral
arterial disease.
Exercise stress echocardiography in patients with aortic stenosis: impact of baseline diastolic dysfunction and functional capacity on mortality and aortic valve replacement
Authors: Andrew N. Rassi, Wael AlJaroudi, Sahar Naderi, M Chadi Alraies, Venu Menon, Leonardo Rodriguez, Richard Grimm, Brian Griffin, Wael A. Jaber
http://www.thecdt.org/article/view/2855
A Study to Assess the Effectiveness of Hibiscus Sabdariffa on Hypertensive Pa...ijtsrd
The present study aim was the assess the effectiveness of hibiscus sabdariffa on hypertensive patients in rural area. A Quantitaive research approach and Quasi experimental pre test and post test control group design have adopted for the present study. 60 participants were selected who are satisfied with inclusion criteria whereas 30 samples in experimental group other 30 sample were in control group, they were selected by convenient sampling technique. A structured questionnaire method to collect the demographic variables and clinical variables, blood pressure is assessed by the sphygmomanometer. Among 60 patient, 30 hypertensive patient participated in the reveals the pretest mean score was 1.83±0.36 and the post test mean score was 1.23±0.66 in systolic blood pressure and the pretest mean score was 1.4±0.48 and post test mean score was 0.5±0.40 in diastolic blood pressure. Paired t test to compare the pre and posttest level of blood pressure among experimental group. The present study regard to the pre and post test level of systolic blood pressure among experimental group it was found that the t value was5.86, With regard to the pre and post test level of diastolic blood pressure among experimental group it was found that the t value was 12.3, indicating that the rewash a highly significant reduction in post test level of blood pressure among the experimental group at p 0.05level. The present study reveals the pretest mean score was 1.83±0.53 and the post test mean score was 1.96 ±1.6 in systolic blood pressure and the pretest mean score was 1.26 ±0.49 and post test mean score was 0.22 ±0.71 in diastolic blood pressure. paired t test to compare the pre and post test level of blood pressure among control group. With regard to the pre and post test level of systolic blood pressure among control group it was found that the t value was 2.35, With regard to the pre and post test level of diastolic blood pressure among control group it was found that the t value was 2.48, indicating that there was no significant reduction in post test level of blood pressure among the control group at p 0.05 level. Sathiyabama. G | Narmadha K | Nivetha. S "A Study to Assess the Effectiveness of Hibiscus Sabdariffa on Hypertensive Patients in Rural Area" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-6 | Issue-6 , October 2022, URL: https://www.ijtsrd.com/papers/ijtsrd52202.pdf Paper URL: https://www.ijtsrd.com/medicine/nursing/52202/a-study-to-assess-the-effectiveness-of-hibiscus-sabdariffa-on-hypertensive-patients-in-rural-area/sathiyabama-g
The document discusses the role of cardiopulmonary exercise testing (CPET) before, during, and after left ventricular assist device (LVAD) implantation for advanced heart failure. CPET is useful diagnostically and prognostically before LVAD implantation to help determine candidacy. It can also help guide cardiac rehabilitation and monitor recovery after LVAD implantation. CPET values are important criteria used to select candidates for LVAD and heart transplantation.
This document summarizes the topics discussed at a journal club meeting led by Dr. Praveen Nagula. It includes discussions on valvular heart disease patterns in India, guidelines for ambulatory blood pressure monitoring, baroreflex activation therapy, electrocardiogram challenges, and the PREVAIL trial. It also reviews the incidence and characteristics of various valvular lesions seen on echocardiography at a large cardiac center in India, highlighting rheumatic heart disease as a major cause. Guidelines for the clinical use and interpretation of ambulatory blood pressure monitoring are summarized.
Risk factors of Acute Coronary Syndrome at Prince Ali Bin Alhussein hospitalMinistry of Health
Objective:The aim of this survey to identify the relationship between ACS and its risk factors and the association between the risks factors themselves. Method: A retrospective study depends on the registered files of the admitted patients to Prince Ali Bin Alhussein hospital with ACS since April 2013 till October of 2013 included 174 patients. Result:The above mentioned data and results show a strong relationship between ACS and the mentioned risk factors. Conclusion: There is a strong relationship between risks factors themselves as D.M and hypertension, and between hypertension with the sex and smoking.There's an association between D.M and the patient's gender
The Association of Left Atrial Enlargement in Different Subtypes of Ischemic ...pateldrona
LAE related rhythm disturbance that characterize atrial fibrillation is also associated with other atrial derangement such as endothelial dysfunction and impaired myocyte function
The Association of Left Atrial Enlargement in Different Subtypes of Ischemic ...AnonIshanvi
LAE related rhythm disturbance that characterize atrial fibrillation is also associated with other atrial derangement such as endothelial dysfunction and impaired myocyte function. The role of LAE in acute cerebral infarction patient is not sufficiently described in literature.
The Association of Left Atrial Enlargement in Different Subtypes of Ischemic ...komalicarol
LAE related rhythm disturbance that characterize atrial fibrillation is
also associated with other atrial derangement such as endothelial dysfunction and impaired myocyte
function. The role of LAE in acute cerebral infarction patient is not sufficiently described in literature.
Hence of this study was undertaken to look for the frequency of left atrial enlargement in acute stroke
subtypes.
Acute Respiratory Distress Syndrome. ppt 2023 Siva P Sivakumar.pptxTamilaruviMuniraj
This document provides an overview of acute respiratory distress syndrome (ARDS). It defines ARDS, describes its risk factors and pathophysiology. Key points include: ARDS involves fluid buildup in the lungs leading to hypoxemia; risk factors include sepsis, pneumonia and trauma; pathophysiology involves damage to the alveolar-capillary barrier allowing fluid influx; mortality has decreased to 30-40% with improved care but remains higher with greater illness severity or older age; complications can include barotrauma from mechanical ventilation.
This document discusses hemodynamic monitoring in critically ill patients. It notes that while hemodynamic monitoring is a cornerstone of management, the utility of most methods is unproven. Physicians have become psychologically dependent on feedback from monitors independent of their effectiveness. The effectiveness of monitoring is limited to specific patient groups and diseases where proven effective treatments exist. The document discusses various hemodynamic monitoring methods including invasive and non-invasive options like arterial catheters, central venous pressure, and echocardiography. It notes that no individual parameter necessarily defines hemodynamic stability and thresholds vary between patients and clinical contexts.
Similar to Samir rafla a-new-score-of-positivity-in-thallium-studies-of-ischemic-patients (20)
This document discusses why every girl is a princess through her relationship with Jesus Christ. It provides six reasons:
1. As daughters of the King (Jesus), girls have inherent worth and should behave as princesses.
2. As ambassadors of Jesus, girls represent him through their conduct and behavior.
3. As servants of Jesus, girls should seek to help others in need on his behalf.
4. Jesus dwells within girls, so they can communicate with him intimately through prayer.
5. Jesus accepts friendship with people and is described as a friend in the Bible.
6. Girls are precious copies of Jesus, with people seeing him through their faces, speech and
This document summarizes recent advances in electrophysiology technologies:
1. New devices include dual chamber leadless pacemakers and a multi-electrode balloon catheter for radiofrequency ablation.
2. Subcutaneous ICDs eliminate transvenous leads, and a leadless CRT system is in development.
3. Improved ablation technologies include laser and radiofrequency balloon catheters.
4. Wearable and implantable devices are replacing Holter monitors for arrhythmia detection.
5. New electroanatomical mapping systems provide higher resolution maps.
6. MRI and ultrasound guidance are being used to visualize ablation effects.
7. Smartwatches can detect atrial fibrillation with E
1) Sudden cardiac death is a major public health problem, causing hundreds of thousands of deaths in the US each year. The most common causes are coronary artery disease and structural heart diseases.
2) Early recognition of SCD and initiation of cardiopulmonary resuscitation significantly improves chances of survival. Defibrillation within 5 minutes of cardiac arrest from ventricular fibrillation is critical.
3) New guidelines emphasize the importance of continuous chest compressions, use of automated external defibrillators, capnography to monitor CPR quality, and therapeutic hypothermia after resuscitation from cardiac arrest.
The document discusses junctional rhythms and disturbances. It describes how junctional rhythms can occur when retrograde conduction is impaired, resulting in AV dissociation with the ventricular rate usually faster than the atrial rate. An accelerated junctional rhythm is seen in patients with heart disease and is commonly caused by digitalis intoxication, acute myocardial infarction, surgery, or myocarditis. Occasionally, there can be exit block of the junctional impulse, slowing the ventricular rate. Junctional rhythms are evaluated based on the relationship between P waves and QRS complexes.
A beautiful paper published by Eugene Braunwald
European Heart Journal, Volume 42, Issue 24, 21 June 2021, Pages 2327–2328, https://doi.org/10.1093/eurheartj/ehab264
The document provides the 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation (AF) developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). It was created by the AF Task Force of the ESC with contributions from the EHRA. The Task Force included experts from various European countries who provided recommendations for the definition of AF, screening, diagnosis, assessment, and integrated management of AF patients. The guidelines represent an update based on recent clinical evidence and aim to improve diagnosis and optimize treatment strategies for AF.
The document is titled "Cardio Alex 2021 Electrophysiology Program" and was uploaded by Samir Rafla. It appears to be information about an electrophysiology program for the year 2021, though no other details are provided in the short title and uploader information given.
The document provides an agenda for the Rare Cardiomyopathies session taking place from 11:00-12:00 in Delegate Hall. It lists the chairpersons and presentations in order, including topics like Arrhythmogenic right ventricular dysplasia, Left ventricular non-compaction cardiomyopathies, Pacing-induced cardiomyopathy, and Peripartum cardiomyopathy. Each presentation is scheduled for 15 minutes including discussion.
God created the heavens and the earth. Initially, the earth was formless and empty with darkness covering the deep. However, the Spirit of God was hovering over the waters. God then spoke light into existence and separated it from the darkness. He called the light "day" and the darkness "night," marking the first day. On the second day, God created an expanse to separate the waters above from the waters below, calling it the "sky."
This document contains the text of the Gospel of John from the Holy Bible. It recounts the works and teachings of Jesus Christ according to the Apostle John. Over 21 chapters, it describes Jesus turning water into wine at a wedding in Cana, cleansing the temple in Jerusalem, conversing with Nicodemus about being born again, speaking with a Samaritan woman at a well, performing miracles such as healing a royal official's son, teaching crowds about being the bread of life, and appearing after his resurrection to his disciples. The Gospel emphasizes Jesus' divine nature and mission to bring salvation and eternal life.
This document is the Gospel of Luke chapters 1-2 from the Holy Bible. It describes the birth and early life of Jesus Christ. In chapter 1, it describes Jesus' conception and the births of John the Baptist and Jesus. Zacharias and Elizabeth conceive John the Baptist, while Mary conceives Jesus after being visited by the angel Gabriel. In chapter 2, it describes Jesus' birth in Bethlehem and presentation at the Temple, as well as his childhood years growing up in Nazareth.
This summary provides the key details from the document in 3 sentences:
The document describes Jesus beginning his ministry by being baptized by John the Baptist. Jesus calls his first disciples and teaches with authority in the synagogues. Jesus heals many who are sick or possessed by demons, and teaches the crowds using parables about the kingdom of God.
The document provides background on the four Gospels of the New Testament - Matthew, Mark, Luke, and John. Though each Gospel was written separately, they all aim to convey God's favor toward humanity through Jesus Christ. The document then focuses on an overview of the Gospel of Matthew, summarizing each chapter in a few sentences to preview the key events and teachings contained therein, such as Jesus' birth, baptism, temptation, and beginning of his ministry.
This document provides information on valvular heart disease, focusing on mitral stenosis and mitral regurgitation. It discusses the etiology, pathophysiology, symptoms, physical exam findings, diagnostic testing, and treatment recommendations for each condition. Mitral stenosis is typically caused by rheumatic fever and leads to pulmonary hypertension from elevated left atrial pressures. Mitral regurgitation can result from several causes including rheumatic heart disease, papillary muscle dysfunction, and mitral valve prolapse. Physical exam findings help distinguish the murmurs associated with each condition. Echocardiography is important for diagnosis and determining treatment approach.
The document discusses approaches to treating different types of ventricular arrhythmias that can occur after a myocardial infarction, including conservative management of premature ventricular contractions, use of antiarrhythmic drugs like lidocaine and amiodarone for ventricular fibrillation and tachycardia, and recognizing reperfusion arrhythmias that may not require treatment. It also provides recommendations for evaluating patients at higher risk of arrhythmias and managing electrical storm through correcting underlying issues, antiarrhythmic drugs, and device programming.
This document summarizes the diagnosis, management, and treatment of COVID-19 infection. It describes the clinical symptoms and stages of the disease from mild to severe. Laboratory findings associated with different stages are provided. The principles of treatment include antiviral drugs, immunomodulators, corticosteroids, and other supportive care. Cardiovascular complications are common and include myocarditis, acute myocardial infarction, and heart failure. One case study describes a patient presenting with fulminant myocarditis and cardiogenic shock due to coronavirus infection who was successfully treated with medications to suppress inflammation, regulate the immune system, and support heart function.
1. Atrial fibrillation (AF) is classified based on duration and presence of symptoms, including first diagnosed, paroxysmal (<7 days), persistent (≥7 days), long-standing persistent (≥12 months), and permanent.
2. Risk factors for incident AF include structural heart disease, hypertension, obesity, smoking, diabetes, and age.
3. Treatment recommendations include long-term antiarrhythmic drugs like amiodarone, dronedarone, and flecainide/propafenone based on patient characteristics, as well as cardioversion and catheter ablation.
This document provides an overview of pacemakers and implantable cardioverter defibrillators (ICDs). It discusses the different types of pacemakers including single-chamber pacemakers (VVI), dual-chamber pacemakers (DDD), and biventricular pacemakers (CRT). It outlines the indications for pacemaker and ICD implantation and reviews potential complications of the procedures such as infection, lead issues, and pacemaker syndrome. Guidelines for device implantation and management are summarized including recommendations on timing after heart events, upgrades, and device selection. Risks associated with dual chamber devices are also mentioned.
This document provides guidelines for the diagnosis and treatment of heart failure, including recommendations on tests such as transthoracic echocardiography, brain natriuretic peptide levels, and cardiac imaging. It discusses the types of heart failure with preserved or reduced ejection fraction. The guidelines also cover medical therapies like angiotensin converting enzyme inhibitors, mineralocorticoid antagonists, angiotensin receptor neprilysin inhibitors, and devices for cardiac resynchronization or left ventricular assistance. Optimum medical therapy is emphasized.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
The droplets have a tendency to conglomerate to one big mass, but on being shaken they fall apart into countless little droplets again. It is used to ignite explosives, like mercury fulminate, the explosive character is one of its general themes.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
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Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
1. Cardiol Cardiovasc Med 2020; 4 (1): 045-057 DOI: 10.26502/fccm.92920101
Cardiology and Cardiovascular Medicine Vol. 4 No. 1 - February 2020. [ISSN 2572-9292] 045
Research Article
A New Score of Positivity in Thallium Studies of Ischemic Patients
Samir Rafla*
, Ahmed Gaber, Gehan Magdy, Ahmed Abdelaaty
Alexandria University, Faculty of Medicine, Cardiology Department, Alexandria, Egypt
*Corresponding author: Samir Rafla, Alexandria University, Faculty of Medicine, Cardiology Department,
Alexandria, Egypt, E-mail: smrafla@yahoo.com
Received: 27 December 2019; Accepted: 06 January 2020; Published: 23 January 2020
Citation: Samir Rafla, Ahmed Gaber, Gehan Magdy, Ahmed Abdelaaty. A New Score of Positivity in Thallium
Studies of Ischemic Patients. Cardiology and Cardiovascular Medicine 4 (2020): 045-057.
Abstract
The aim of this work was to detect means to increase
accuracy of prediction of Thallium perfusion results.
Also, we aimed to investigate the incidence and severity
of chest pain during radionuclide myocardial perfusion
imaging and its relation to the stress modality.
The study was conducted on two groups of patients that
presented for radionuclide myocardial perfusion
imaging. The first group included fifty patients
subjected to exercise stress testing. The second group
included fifty patients subjected to dipyridamole
pharmacologic stress testing. The 2 groups were
compared regarding chest pain, dyspnea,
electrocardiographic changes, left ventricular dilatation,
and increased lung thallium uptake. Exercise was
associated with a statistically significant higher
incidence and severity of chest pain compared to
dipyridamole (p<0.001). The incidence and severity of
chest pain were related to the number of vessel
territories affected in the dipyridamole group (p=0.037),
but not in the exercise group. Exercise was associated
with a statistically significant higher incidence of
electrocardiographic (ECG) changes compared to
dipyridamole (p<0.001). There was no statistically
significant difference in the incidence of left ventricular
dilatation between the 2 groups. The incidence of left
ventricular dilatation was related to the number of
vessel territories affected in the exercise group
(p=0.011) as well as the dipyridamole group (p=0.007).
There was no statistically significant difference in the
incidence of increased lung thallium-201 uptake
between the 2 groups. The incidence of increased lung
thallium-201 uptake was related to the number of vessel
territories affected in the exercise group (p=0.017) but
not in the dipyridamole group.
We summed four parameters 1- chest pain (one or two
or three points), 2- ECG changes > 1mm (two points),
3- LV dilation (two points), and 4- Lung thallium
2. Cardiol Cardiovasc Med 2020; 4 (1): 03945-057 DOI: 10.26502/fccm.92920101
Cardiology and Cardiovascular Medicine Vol. 4 No. 1 - February 2020. [ISSN 2572-9292] 046
uptake (two points), so maximum can be 9 points for
each patient. We compared the results in every patient
with the degree of perfusion defects (meaning number
of vessels affected) (each vessel territory if it shows
perfusion defect is given two points; three vessel areas
are given 6 points). Correlation revealed significant
relation P <0.05 thus we postulated new score of
validation of positivity of perfusion defects, the higher
the score of these parameters the higher the expected
percent of perfusion defect; that is confirmation of
positivity of ischemia. To our knowledge this is new
score of assessing thallium perfusion.
Keywords: Radionuclide myocardial perfusion;
Imaging; ischemic heart disease; Dipyridamole;
Exercise stress test; Thallium
Abbreviations
Myocardial perfusion imaging (MPI); Lung/heart ratio
(LHR); Single photon emission computed tomography
(SPECT); Coronary artery disease (CAD); Adenosine
triphosphate (ATP); Verbal rating scale (VRS).
Introduction
Ischemic heart disease (IHD) is becoming a major
health problem affecting many parts of the world. In
Egypt, ischemic heart disease affected more than 2.5
million individuals in 2016 [1] and caused more than
144 thousand deaths [2].
Chest pain remains the second most common cause of
non-injury related emergency department visits.
Although the presence of chest pain raises the suspicion
of myocardial ischemia, only 13% of the emergency
department visits for chest pain are diagnosed with
acute coronary syndrome [4,5].
A multitude of investigative tools are available for the
assessment of chest pain. Radionuclide myocardial
perfusion imaging is a well-established non-invasive
imaging technique that provides both diagnostic and
prognostic data. Radionuclide myocardial perfusion
imaging uses intravenous radiopharmaceuticals that
distributes to the myocardium in proportion to regional
myocardial perfusion to assess myocardial perfusion
during stress and rest. Myocardial distribution of the
radiopharmaceutical is compared in states of stress and
rest to provide information on perfusion anomalies,
myocardial viability, and, when electrocardiographic
gating is used, myocardial function [6,7].
Stress is achieved by exercise or pharmacologic agents.
Exercise stress is preferred over pharmacologic agents
as it is the most physiological form of cardiac stress, it
allows the assessment of exercise capacity, heart rate
and blood pressure responses including reserve and
recovery, and the development of symptoms which are
useful for clinical decision making. Additionally,
exercise stress offers superior image quality compared
with pharmacologic vasodilator stress due to splanchnic
vasoconstriction which allows for a smaller proportion
of the injected radiopharmaceutical tracer to appear in
the gut [8]. Within normal coronary territories, exercise
stress increases coronary blood flow 2-3 folds as a
secondary effect to increased myocardial oxygen
demand [9].
For patients unable to exercise or achieve an adequate
level of exercise pharmacologic stress is used. The
vasodilator pharmacologic stress agents used are
adenosine, dipyridamole, or regadenoson. These agents
increase the coronary blood flow 3-5 folds within
normal coronary territories which are significantly
higher than exercise and inotropic pharmacologic stress,
however, vasodilator pharmacologic stress does not
produce greater heterogenicity in perfusion between
normal and abnormal coronary territories compared to
exercise and inotropic pharmacologic stress. This is due
to the plateauing relation between perfusion and uptake
3. Cardiol Cardiovasc Med 2020; 4 (1): 03945-057 DOI: 10.26502/fccm.92920101
Cardiology and Cardiovascular Medicine Vol. 4 No. 1 - February 2020. [ISSN 2572-9292] 047
of the available radiopharmaceutical tracers at higher
flow rates. This is known as the roll-off phenomenon
[9]. In most cases perfusion heterogenicity occurs in the
absence of metabolic ischemia, as myocardial oxygen
demand is not affected [10].
The aim of this work was to investigate the incidence
and severity of chest pain during radionuclide
myocardial perfusion imaging and its relation to the
stress modality used and the findings of the radionuclide
myocardial perfusion imaging.
Methods
This study was conducted retrospectively and
prospectively on two groups of patients that presented
for radionuclide myocardial perfusion imaging. All the
100 patients had positive Thallium result i.e. showed
perfusion defects.
1. The first group: fifty patients subjected to
exercise stress testing, twenty-five cases were
prospective, and twenty-five cases were
retrospective.
2. The second group: fifty patients subjected to
dipyridamole pharmacologic stress testing,
twenty-five cases were prospective, and
twenty-five cases were retrospective.
Exclusion criteria included assessment of myocardial
viability through rest-redistribution protocol with no
cardiac stress; the presence of contraindication to
cardiac stress test, severe valvular heart disease, severe
heart failure, or pregnancy, and inability to obtain
patient’s consent.
Patients were subjected to detailed history taking
including personal data, risk factors, current complaint
and its analysis, medical conditions, medications, and
previous surgeries. Patients were also subjected to full
cardiac examination.
For the first group myocardial stress was achieved by
treadmill exercise through the Bruce protocol.
The radiopharmaceutical was injected just prior to peak
exercise followed by saline flush. Peak exercise was
marked by the sustained achievement of target heart
rate, that is, 85% of maximum predicted heart rate (220
– age for males, 210 – age for females) or the
development of limiting chest pain. Patient continued to
exercise for 1 minute following radiopharmaceutical
injection before starting recovery. Heart rate, blood
pressure, and 12-lead ECG were monitored for 4
minutes into recovery, or longer if chest pain or
ischemic ECG changes were found.
For the second group myocardial stress was achieved by
dipyridamole. Dipyridamole acts by increasing the
extracellular concentration of endogenous adenosine
which causes coronary vasodilatation and increases
myocardial perfusion. Heart rate, blood pressure, and
12-lead ECG were recorded prior to dipyridamole
injection. Dipyridamole (0.56 mg/kg diluted with 0.9%
saline in a 10-ml syringe) was injected by hand over 4
minutes. Heart rate, blood pressure, and 12-lead ECG
were recorded every 2 minutes or if side effects as chest
pain, dyspnea, and dizziness developed. The
radiopharmaceutical was injected 3-4 minutes after
dipyridamole injection.
Thallium-201 (80 MBq) was injected during stress.
Stress image acquisition was done 5-10 minutes post
injection, while redistribution image acquisition was
done 4 hours post injection. Image acquisition was done
using Symbia E dual head multi-purpose SPECT
system. Image interpretation was performed by
experienced staff members of Alexandria university
nuclear cardiology lab. Diagnostic criteria were based
on the detection of reversible perfusion defects
(considered as myocardial ischemia). No quantitative
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analysis was used, but rather the visual analysis of
experienced observers.
Statistics: Data were fed to the computer and analyzed
using IBM SPSS software package version 20.0.
(Armonk, NY: IBM Corp). Qualitative data were
described using number and percent. The Kolmogorov-
Smirnov test was used to verify the normality of
distribution Quantitative data were described using
range (minimum and maximum), mean, standard
deviation and median. Significance of the obtained
results was judged at the 5% level. The tests used were
Chi-square test, Fisher’s Exact, Monte Carlo correction,
Student t-test, Mann Whitney test, and Spearman
coefficient.
Results
Table 1: Relation between number of vessel territories affected and different parameters in the exercise group
Number of vessel territories affected
Test of
Sig.
p
1 Vessel territory
(n=21)
2 Vessels territories
(n=21)
3 Vessels territories
(n=8)
No. No. No.
NYHA class
Class I 0 0.0 3 14.3 0 0.0
χ2
=
8.187
MC
p=
0.052
Class II 15 71.4 10 47.6 2 25.0
Class III 6 28.6 8 38.1 6 75.0
Class IV 0 0.0 0 0.0 0 0.0
VRS chest pain
No pain 9 42.9 10 47.6 3 37.5
χ2
=
2.723
MC
p=
0.896
Mild pain 6 28.6 3 14.3 1 12.5
Moderate pain 2 9.5 3 14.3 1 12.5
Severe pain 4 19.0 5 23.8 3 37.5
ECG changes
No 8 38.1 8 38.1 2 25.0 χ2
=
0.500
0.779
Yes 13 61.9 13 61.9 6 75.0
LV dilatation
No 17 81.0 11 52.4 2 25.0
8.285*
MC
p=
0.011*
Yes 4 19.0 10 47.6 6 75.0
Increased lung
thallium-201 uptake
No 21 100.0 15 71.4 6 75.0 χ2
=
7.817*
MC
p=
0.017*
Yes 0 0.0 6 28.6 2 25.0
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Number of vessel territories affected
Test of
Sig.
p
1 Vessel territory
(n=26)
2 Vessels
territories
(n=18)
3 Vessels
territories
(n=6)
No. No. No.
NYHA class
Class I 1 3.8 0 0.0 0 0.0
χ2
=
3.764
MC
p=
0.789
Class II 14 53.8 8 44.4 2 33.3
Class III 9 34.6 9 50.0 4 66.7
Class IV 2 7.7 1 5.6 0 0.0
VRS chest pain
No pain 25 96.2 16 88.9 4 66.7
χ2
=
10.118*
MC
p=
0.037*
Mild pain 1 3.8 0 0.0 0 0.0
Moderate pain 0 0.0 1 5.6 0 0.0
Severe pain 0 0.0 1 5.6 2 33.3
ECG changes
No 21 80.8 16 88.9 3 50.0 χ2
=
3.826
MC
p=
0.126Yes 5 19.2 2 11.1 3 50.0
LV Dilatation
No 17 65.4 7 38.9 0 0.0 χ2
=
9.289*
MC
p=
0.007*
Yes 9 34.6 11 61.1 6 100.0
Increased lung
thallium-201 uptake
No 21 80.8 12 66.7 5 83.3 χ2
=
1.314
MC
p=
0.519Yes 5 19.2 6 33.3 1 16.7
Table 2: Relation between number of vessels territories affected and different parameters in dipyridamole group
Test hemodynamic response
Within the exercise group the resting heart rate ranged
from 55 to 115 beats per minute with a mean of 78.5 ±
15.4 beats per minute. Peak heart rate ranged from 85 to
179 beats per minute with a mean of 134.8 ± 21.7 beats
per minute. Exercise induced a mean increase of 56.2 ±
22.2 beats per minute in heart rate.
The resting systolic blood pressure ranged from 100 to
160 mmHg with a mean of 127.7 ± 15.56 mmHg. Peak
systolic blood pressure ranged from 70 to 200 mmHg
with a mean of 146.6 ± 21.53 mmHg. Exercise induced
a mean increase of 18.90 ± 18.39 mmHg in systolic
blood pressure.
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The resting diastolic blood pressure ranged from 60 to
100 mmHg with a mean of 78.80 ± 7.46 mmHg. Peak
diastolic blood pressure ranged from 40 to 110 mmHg
with a mean of 86.98 ± 11.45 mmHg. Exercise induced
a mean increase of 8.18 ± 9.64 mmHg in diastolic blood
pressure.
Within the dipyridamole group the resting heart rate
ranged from 55 to 120 beats per minute with a mean of
81.40 ± 13.37 beats per minute. Peak heart rate ranged
from 61 to 121 beats per minute with a mean of 86.90 ±
13.80 beats per minute. Dipyridamole induced a mean
increase of 5.50 ± 8.63 beats per minute in heart rate.
The resting systolic blood pressure ranged from 100 to
200 mmHg with a mean of 136.8 ± 24.11 mmHg. Peak
systolic blood pressure ranged from 90 to 220 mmHg
with a mean of 135.7 ± 27.81 mmHg. Dipyridamole
induced a mean decrease of -1.10 ± 18.77 mmHg in
systolic blood pressure.
The resting diastolic blood pressure ranged from 60 to
100 mmHg with a mean of 82.80 ± 10.31 mmHg. Peak
diastolic blood pressure ranged from 60 to 120 mmHg
with a mean of 83.80 ± 13.23 mmHg. Dipyridamole
induced a mean increase of 1.0 ± 10.74 mmHg in
diastolic blood pressure.
Comparison of the two groups according to chest
pain and other ischemic parameters
Within the exercise group 22 patients (44%)
experienced no chest pain during the test, 10 patients
(20%) had mild chest pain, 6 patients (12%) had
moderate chest pain, and 12 patients (24%) had severe
chest pain.
ECG changes occurred in 32 patients (64%), increased
lung thallium-201 uptake occurred in 8 patients (16%),
and left ventricular dilatation occurred in 20 patients
(40%) out of which 8 patients had preexisting dilatation
that increased during the test.
Within the dipyridamole group 45 patients (90%)
experienced no chest pain during the test, 1 patient (2%)
had mild chest pain, 1 patient (2%) had moderate chest
pain, and 3 patients (6%) had severe chest pain.
ECG changes occurred in 10 patients (20%), increased
lung thallium-201 uptake occurred in 12 patients (24%),
and left ventricular dilatation occurred in 26 patients
(52%) out of which 14 patients had preexisting
dilatation that increased during the test.
Comparison of the two groups according to the
results of myocardial perfusion imaging
Within the exercise group 21 patients (42%) had
ischemia in 1 vessel territory, of these 5 patients (10%)
had ischemia in the left anterior descending artery
(LAD) territory, 11 patients (22%) had ischemia in the
right coronary artery (RCA) territory, and 5 patients
(10%) had ischemia in the Left circumflex artery (LCX)
territory.
21 patients (42%) had ischemia in 2 vessels territories,
of these 11 patients (22%) had ischemia in the left
anterior descending artery (LAD) and the right coronary
artery (RCA) territories, 8 patients (16%) had ischemia
in the left anterior descending artery (LAD) and the Left
circumflex artery (LCX) territories, and 2 patients (4%)
had ischemia in the right coronary artery (RCA) and the
Left circumflex artery (LCX) territories. 8 patients
(16%) had ischemia in 3 vessels territories.
Collectively, ischemia within the left anterior
descending artery (LAD) territory was present in 32
patients (64%), ischemia within the right coronary
artery (RCA) territory was present in 32 patients (64%),
7. Cardiol Cardiovasc Med 2020; 4 (1): 03945-057 DOI: 10.26502/fccm.92920101
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and ischemia within the left circumflex artery (LCX)
territory was present in 23 patients (46%).
Within the dipyridamole group 26 patients (52%) had
ischemia in 1 vessel territory, of these 16 patients (32%)
had ischemia in the left anterior descending artery
(LAD) territory, 7 patients (14%) had ischemia in the
right coronary artery (RCA) territory, and 3 patients
(6%) had ischemia in the Left circumflex artery (LCX)
territory.
18 patients (36%) had ischemia in 2 vessels territories,
of these 8 patients (16%) had ischemia in the left
anterior descending artery (LAD) and the right coronary
artery (RCA) territories, 7 patients (14%) had ischemia
in the left anterior descending artery (LAD) and the Left
circumflex artery (LCX) territories, and 3 patients (6%)
had ischemia in the right coronary artery (RCA) and the
Left circumflex artery (LCX) territories. 6 patients
(12%) had ischemia in 3 vessels territories.
Collectively, ischemia within the left anterior
descending artery (LAD) territory was present in 37
patients (74%), ischemia within the right coronary
artery (RCA) territory was present in 24 patients (48%),
and ischemia within the left circumflex artery (LCX)
territory was present in 19 patients (38%).
Relation between the number of vessel territories
affected and different parameters
Within the exercise group the increase in the number of
vessel territories affected was related to the occurrence
of left ventricular dilatation and the increase in lung
thallium-201 uptake.
While within the dipyridamole group the increase in the
number of vessel territories affected was related to the
occurrence of left ventricular dilatation and the
incidence and severity of chest pain during the test.
We postulated new score of positivity or significance of
thallium results, the higher the score the more evidence
of multivessel disease or significant lesions: Criteria or
parameters used are:
Severity of chest pain 1 for mild, 2 for moderate, 3 for
severe pain
LV dilatation 2 points
Lung uptake of thallium (denotes LV dysfunction) 2
points
ST depression >1 mm = 2 points
If one gets all parameters positive, his total score will be
9
Perfusion defects one vessel area = 2 point, 2 vessel
areas = 4, 3 vessel areas= 6
We compared the score with the degree of perfusion
defect; we found significant correlation between the
measured parameters and the severity of perfusion
defects <0.05 in both groups exercise and dipyridamole
groups. This should not be unexpected as it is logic the
severer the ischemia by perfusion the more the clinical
(pain and ST depression) and more Thallium findings
(LV dilatation and Lung Thallium uptake). In some
patients there were more perfusion defects than the 4
parameters, in others more positive parameters than
perfusion defects.
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Total score
rs p
Perfusion defect degree 0.457*
0.001*
Table 3: Exercise Correlation between total score and perfusion defect degree (n = 50)
rs: Spearman coefficient *: Statistically significant at p ≤ 0.05
Total score
rs p
Perfusion defect degree 0.457*
0.001*
Table 4: Dipyridamole Correlation between total score and perfusion defect degree (n = 50)
rs: Spearman coefficient
*: Statistically significant at p ≤ 0.05
Figure 1: A 60 years old male patient presented to Alexandria university nuclear cardiology lab for assessment of
class II chest pain. The patient was diabetic and had history of ischemic heart disease. The patient was not receiving
any medications. The patient underwent exercise single photon emission computed tomography (SPECT)
myocardial perfusion imaging (MPI) using Bruce protocol. During the test, heart rate increased from 60 beats per
minute to 146 beats per minute, systolic blood pressure increased from 130 mmHg to 150 mmHg, and diastolic
blood pressure increased from 80 mmHg to 100 mmHg. Moderate chest pain and ECG changes occurred with stress.
The test result showed ischemia in the left anterior descending (LAD) artery and the right coronary artery (RCA)
territories, both left and right ventricle dilatation during rest that increased during stress, and no increased lung
thallium-201 uptake. Our clinical score 2+2. Thallium score 2+2
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Figure 2: A 61 years old male patient presented to Alexandria university nuclear cardiology lab for assessment of
class III chest pain and dyspnea. The patient was smoker and hypertensive. The patient was not receiving any
medications. The patient underwent pharmacologic single photon emission computed tomography (SPECT)
myocardial perfusion imaging (MPI) using dipyridamole. During the test, heart rate increased from 69 beats per
minute to 76 beats per minute, systolic blood pressure decreased from 140 mmHg to 130 mmHg, and diastolic blood
pressure decreased from 90 mmHg to 80 mmHg. Severe chest pain and ECG changes occurred during the test which
warranted the use of nitrate. The test result showed ischemia in the left anterior descending (LAD) artery, the right
coronary artery (RCA), and the Left circumflex (LCX) artery territories, left ventricle dilatation during stress, and no
increased lung thallium-201 uptake. Our clinical score 3+2+2; thallium score 2+2+2.
Discussion
Chest pain
In single photon emission computed tomography
(SPECT) myocardial perfusion imaging (MPI), clinical
studies report chest pain as either present or absent with
no regard to its type, location, or degree [11,12].
In this study we applied the verbal rating scale (VRS) to
assess chest pain during and after the test. Chest pain
occurred in 56% of the exercise group compared to only
10% of the dipyridamole group. We found that exercise
was associated with a statistically significant higher
incidence and severity of chest pain compared to
dipyridamole (χ2=24.350, MC
p<0.001). The incidence
and severity of chest pain were related to the number of
vessel territories affected in the dipyridamole group
(χ2=10.118, MC
p=0.037), but not in the exercise group.
One study by Chow et al. comparing exercise and
dipyridamole as modes of stress for Positron emission
tomography (PET) myocardial perfusion imaging (MPI)
within same group of patients found that chest pain was
higher with dipyridamole (62%) compared with exercise
(38%) [12].
In a study aimed to evaluate a combined exercise stress
and dipyridamole stress protocol, Cortinas et al.
compared 3 groups that underwent single photon
emission computed tomography (SPECT) myocardial
perfusion imaging (MPI) using 3 different strategies for
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stress, namely, exercise only protocol, dipyridamole
only protocol, or combined exercise and dipyridamole
protocol and reported the occurrence of chest
discomfort only in 10% of the cases of the dipyridamole
only protocol group [13].
Electrocardiographic (ECG) changes
In this study we compared the incidence of
electrocardiographic (ECG) changes between the
exercise group and the dipyridamole group.
Electrocardiographic (ECG) changes occurred in 64%
of the exercise group compared to only 20% of the
dipyridamole group. We found that exercise was
associated with a statistically significant higher
incidence of electrocardiographic (ECG) changes
compared to dipyridamole (χ2=19.869, p<0.001). The
incidence of electrocardiographic (ECG) changes was
not related to the number of vessel territories affected in
any of the 2 groups.
Chow et al. found that electrocardiographic (ECG)
changes were higher with exercise (70%) compared
with dipyridamole (30%) despite chest pain being
higher with dipyridamole compared with exercise [12].
Left ventricular dilatation
In this study we compared the incidence of left
ventricular dilatation between the exercise group and
the dipyridamole group. Left ventricular dilatation
occurred in 40% of the exercise group (out of which
16% had preexisting left ventricular dilatation that
increased with stress) compared to 52% of the
dipyridamole group (out of which 28% had preexisting
left ventricular dilatation that increased with stress).
There was no statistically significant difference in the
incidence of left ventricular dilatation between the 2
groups. The incidence of left ventricular dilatation was
related to the number of vessel territories affected in the
exercise group (χ2=8.285, MC
p=0.011) as well as the
dipyridamole group (χ2=9.289, MC
p=0.007).
In a study aimed to develop normal limits and evaluate
diagnostic power of transient left ventricular dilatation
Sestamibi, Xu et al. demonstrated an increase in
transient left ventricular dilatation with the increase in
coronary artery disease severity. Transient left
ventricular dilatation occurred in 5% of subjects with
insignificant coronary artery disease, 15% of subjects
with moderate coronary artery disease, and more than
24% of subjects with severe coronary artery disease
[14].
Hansen et al. evaluated the relationship between
elevated lung/heart ratio (LHR) and transient left
ventricular dilatation after exercise single photon
emission computed tomography (SPECT) myocardial
perfusion imaging (MPI) and reported that transient left
ventricular dilatation occurred in 7.8% of the subjects
[15-18].
Increased lung thallium-201 uptake
In this study we compared the incidence of increased
lung thallium-201 uptake between the exercise group
and the dipyridamole group. Increased lung thallium-
201 uptake occurred in 16% of the exercise group
compared to 24% of the dipyridamole group. There was
no statistically significant difference in the incidence of
increased lung thallium-201 uptake between the 2
groups. The incidence of increased lung thallium-201
uptake was related to the number of vessel territories
affected in the exercise group (χ2=7.817, MC
p=0.017)
but not in the dipyridamole group.
Choy and Leslie investigated increased lung uptake of
technetium-99m Sestamibi during exercise,
dipyridamole, or combined exercise/dipyridamole single
photon emission computed tomography (SPECT)
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myocardial perfusion imaging (MPI) and its relation to
the severity of coronary artery disease (CAD) and
reported no significant difference in lung/heart ratio
(LHR) among the 3 groups. Additionally, lung/heart
ratio (LHR) showed a positive correlation with the
number of diseased vessels and the coronary artery
disease severity score [19-22].
The mechanism of dipyridamole action is different and
does not involve the myocardial ischemia process.
Dipyridamole inhibits facilitated transport of adenosine
into cells and thus increases extracellular endogenous
adenosine level leading to coronary vasodilatation.
However, dipyridamole may occasionally provoke
myocardial ischemia by a steal effect, via collaterals
from a low flow abnormal capillary bed into a high flow
normal coronary territory and consequently may be
associated with chest pain [10].
In general, chest pain and other ischemic parameters can
be an indicator to the presence and the extent of
ischemic heart disease.
In our study we postulated a new score that proved able
to predict severity of thallium perfusion defects.
Conclusion
Despite having the same end result of achieving
heterogenous perfusion between segments supplied by
normal vessels and segments supplied by diseased
vessels, exercise stress and vasodilator pharmacologic
stress act through different mechanisms.
Occasional myocardial ischemia may develop during
dipyridamole stress by steal effect via collaterals from a
low flow abnormal capillary bed into a high flow
normal coronary territory.
Myocardial ischemia is the cause of chest pain and
electrocardiographic (ECG) changes during single
photon emission computed tomography (SPECT)
myocardial perfusion imaging (MPI). Left ventricular
dilatation and increased lung thallium-201 uptake are
related to the extent of myocardial ischemia.
Our new score of adding 4 parameters together was
correlated with the severity of perfusion defects. These
were 1-chest pain, 2-ECG changes, 3-Lung thallium
uptake and 4- LV dilatation.
Conflict of interest: None
Ethical standards: Full consent was taken from
patients, studies were done for benefit of the patient.
Funding: none
References
1. Hay SI, Abajobir AA, Abate KH, Abbafati C,
Abbas KM, Abd-Allah F, et al. Global,
regional, and national disability-adjusted life-
years (DALYs) for 333 diseases and injuries
and healthy life expectancy (HALE) for 195
countries and territories, 1990–2016: a
systematic analysis for the Global Burden of
Disease Study 2016. Lancet 390 (2017):1260-
1344.
2. Naghavi M, Abajobir AA, Abbafati C, Abbas
KM, Abd-Allah F, Abera SF, et al. Global,
regional, and national age-sex specific
mortality for 264 causes of death, 1980–2016:
a systematic analysis for the Global Burden of
Disease Study 2016. The Lancet 390 (2017):
1151-1210.
3. Wang H, Naghavi M, Allen C, Barber RM,
Bhutta ZA, Carter A, et al. Global, regional,
and national life expectancy, all-cause
mortality, and cause-specific mortality for 249
causes of death, 1980–2015: a systematic
12. Cardiol Cardiovasc Med 2020; 4 (1): 03945-057 DOI: 10.26502/fccm.92920101
Cardiology and Cardiovascular Medicine Vol. 4 No. 1 - February 2020. [ISSN 2572-9292] 056
analysis for the Global Burden of Disease
Study 2015. Lancet 388 (2016): 1459-1544.
4. Bhuiya FA, Pitts SR, McCaig LF. Emergency
department visits for chest pain and abdominal
pain: United States, 1999-2008. NCHS Data
Brief 43 (2010): 1–8.
5. Hoorweg BB, Willemsen RT, Cleef LE,
Boogaerts T, Buntinx F, Glatz JF, et al.
Frequency of chest pain in primary care,
diagnostic tests performed and final diagnoses.
Heart 103 (2017): 1727-1732.
6. Loong CY. Diagnosis of coronary artery
disease by radionuclide myocardial perfusion
imaging. Heart 90 (2004): 2–9.
7. Anagnostopoulos C. Procedure guidelines for
radionuclide myocardial perfusion imaging.
Heart 90 (2004):1i–10.
8. Arbit B, Azarbal B, Hayes SW, Gransar H,
Germano G, Friedman JD, et al. Prognostic
Contribution of Exercise Capacity, Heart Rate
Recovery, Chronotropic Incompetence, and
Myocardial Perfusion Single-Photon Emission
Computerized Tomography in the Prediction of
Cardiac Death and All-Cause Mortality. Am J
Cardiol 116 (2015): 1678-1684.
9. Salerno M, Beller GA. Noninvasive
Assessment of Myocardial Perfusion. Circ
Cardiovasc Imaging 2 (2009): 412-424.
10. Sabharwal N, Arumugam P, Kelion A. Nuclear
cardiology. Second edition. Oxford: Oxford
University Press 2017: 293.
11. Unal K, Akdemir O, Unlu M, Guner L.
Clinical evaluation of the ACCF/ASNC
appropriateness criteria for myocardial
perfusion SPECT imaging. J Nucl Med 54
(2013): 1706–1706.
12. Chow BJW, Ananthasubramaniam K, deKemp
RA, Dalipaj MM, Beanlands RSB, Ruddy TD.
Comparison of treadmill exercise versus
dipyridamole stress with myocardial perfusion
imaging using rubidium-82 positron emission
tomography. J Am Coll Cardiol 45 (2005):
1227–1234.
13. Cortinas IV, Beretta M, Alonso O, Mut F. New
Exercise-Dipyridamole Combined Test for
Nuclear Cardiology in Insufficient Effort:
Appropriate Diagnostic Sensitivity Keeping
Exercise Prognosis. Arq Bras Cardiol 105
(2015): 123-129.
14. Xu Y, Arsanjani R, Clond M, Hyun M, Lemley
M, Fish M, et al. Transient ischemic dilation
for coronary artery disease in quantitative
analysis of same-day sestamibi myocardial
perfusion SPECT. J Nucl Cardiol 19 (2012):
465-473.
15. Hansen CL, Sangrigoli R, Nkadi E, Kramer M.
Comparison of pulmonary uptake with
transient cavity dilation after exercise thallium-
201 perfusion imaging. J Am Coll Cardiol 33
(1999):1323–1327.
16. Kinoshita N, Sugihara H, Adachi Y, Nakamura
T, Azuma A, Kohno Y, et al. Assessment of
transient left ventricular dilatation on rest and
exercise on Tc-99m tetrofosmin myocardial
SPECT. Clin Nucl Med 27 (2002): 34–39.
17. Rischpler C, Higuchi T, Fukushima K, Javadi
MS, Merrill J, Nekolla SG, et al. Transient
Ischemic Dilation Ratio in 82Rb PET
Myocardial Perfusion Imaging: Normal Values
and Significance as a Diagnostic and
Prognostic Marker. J Nucl Med 53 (2012):
723-730.
18. Chouraqui P, Rodrigues EA, Berman DS,
Maddahi J. Significance of dipyridamole-
induced transient dilation of the left ventricle
during thallium-201 scintigraphy in suspected
coronary artery disease. Am J Cardiol 66
(1990): 689–694.
13. Cardiol Cardiovasc Med 2020; 4 (1): 03945-057 DOI: 10.26502/fccm.92920101
Cardiology and Cardiovascular Medicine Vol. 4 No. 1 - February 2020. [ISSN 2572-9292] 057
19. Choy JB, Leslie WD. Clinical correlates of Tc-
99m sestamibi lung uptake. J Nucl Cardiol Off
Publ Am Soc Nucl Cardiol 8 (2001): 639–644.
20. Leslie WD, Tully SA, Yogendran MS, Ward
LM, Nour KA, Metge CJ. Prognostic Value of
Lung Sestamibi Uptake in Myocardial
Perfusion Imaging of Patients With Known or
Suspected Coronary Artery Disease. J Am Coll
Cardiol 45 (2005): 1676–1682.
21. Patel GM, Hauser TH, Parker JA, Pinto DS,
Sanders GP, Aepfelbacher FC, et al.
Quantitative relationship of stress Tc-99m
sestamibi lung uptake with resting Tl-201 lung
uptake and with indices of left ventricular
dysfunction and coronary artery disease. J Nucl
Cardiol Off Publ Am Soc Nucl Cardiol 11
(2004): 408–413.
22. Georgoulias P, Tsougos I, Valotassiou V,
Tzavara C, Xaplanteris P, Demakopoulos N.
Long-term prognostic value of early post stress
99mTc-tetrofosmin lung uptake during
exercise (SPECT) myocardial perfusion
imaging. Eur Eur J Nucl Med Mol Imaging 37
(2010): 789-798.
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