Aortic Stenosis -Pitfalls

https://youtu.be/pTOLcteQAns

Tricuspid Regurgitation

The images are not of the best quality, poor actually but good enough to see why this patient has severe LE edema  and a  pulsating V- wave on neck exam ....but what's the cause ?
This is not a made up case , this was a former patient.

Position of Cardiac Devices on CXR

This website is a good review for placement and complication recognition of cardiac devices.

What surgery had the patient above done ? Patient seen this morning on admission and recent history of SBE.

Ischemic Stroke Risk In Patients with Non- Valvular Atrial Fibrillation

• • Ischemic stroke risk prediction is a cornerstone in the management of patients with atrial fibrillation.
• • The paper reviews the evolution of these risk scores, discusses their strengths and limitations, and appraises the emerging risk assessment tools and their incremental utility.
• • There is an unmet need for a comprehensive study incorporating various clinical, anatomic, and biophysiological risk factors to optimize our stroke prevention practices in patients with atrial fibrillation.

GARFIELD-AF Risk Calculator

GARFIELD -AF RISK CALCULATOR

GARFIELD-AF Risk Calculator

GARFIELD-AF Risk Calculator

Left Bundle Branch Pacing

• • Pathological damage in cardiac conduction system leads to symptomatic bradycardia and electric dyssynchrony and is associated with an increased risk for heart failure.
• • Traditional pacing modalities are nonphysiological, which may limit clinical response.
• • LBBP can bypass the pathological or disease-vulnerable region in the cardiac conduction system to produce near physiological or true conduction system pacing for patients in need of ventricular pacing for bradycardia or heart failure.

Mechanical Ventilation of the Very Obese Patient

His Pacing

I am posting this webinar in follow up to a case previously posted in the EKG pages ( RV apical pacing leading to acute MR and APE). I did not report the NT-pro BNP post RV apical pacing but it was 38,421 pg/ml.
With 4 L diuresis  in 24 hours,the patient improved but is sill not optimal and will need His spacing or BiV pacing/CRT-P

Association Between Volume of Fluid Resuscitation and Intubation in High-Risk Patients with Sepsis, Heart Failure, End-Stage Renal Disease, and Cirrhosis.

Study: Association Between Volume of Fluid Resuscitation and Intubation in High-Risk Patients with Sepsis, Heart Failure, End-Stage Renal Disease, and Cirrhosis. Khan et al. CHEST 2019.

Clinical question: In patients with sepsis and septic shock who have co-morbid conditions of CHF, ESRD and Cirrhosis, is the full 30 cc/kg IVF bolus associated with higher rates of intubation?

Methods:

Single center, retrospective study

Included patients with CHF (HFrEF, HFpEF), ESRD and Cirrhosis

Sepsis identified through APACHE database, ICD9 and 10 codes followed by trained clinician review based on a published clinical sepsis surveillance definition

Calculated IVF given as bolus fluids in the first 6 hours of hospital arrival; did not include maintenance fluids given in first 6 hours, also did not include fluids given by EMS personnel prior to hospitalization

Primary outcome: Intubation within 72 hours from fluid bolus

Secondary outcomes:

-          Time to intubation

-          Change in oxygen requirement

-          Alive ICU free days

-          Ventilator days

-          Hospital mortality

Included patients assigned to 1 of 2 cohorts:

-          > 30 cc/kg IVF (standard group)

-          < 30 cc/kg IVF (restricted group)

Results:

286 patients included, 208 matched patients (104 standard resuscitation, 104 restrictive group)

No statistical differences between patient characteristics and clinical variables between groups except for:

-          Fluid volume in first 6 hours 1.39 +/- 700 L (restricted) vs 3.38 +/- 1.06 L (standard) (p < 0.001)

-          Fluid volume in first 24 hours 2.38 +/- 1.35 L vs 4.38 +/- 1.61 L (p < 0.01)

-          Fluid balance at 72 hours approached a significant difference 3.17 L vs 4.20 L (p = 0.054)

-          DNI status 3% (restricted) vs 11% (standard)

Notably, there were no differences in vasopressor or diuretic use in the first 72 hours or differences in rates of non-invasive ventilation.

There were no differences in the primary or secondary study outcomes:

After adjustment for APACHE III score, lactate level, steroid use, change in oxygen requirement from baseline, noninvasive ventilation use, fluid balance at 72 h, DNI status, and presence of CHF, cirrhosis, or ESRD with multivariable generalized estimating equation, administration of > 30 mL/kg fluid resuscitation (standard resuscitation) was not independently associated with intubation (P = .34).

Strengths:

-          This trial asks an important question. Early and aggressive IVF resuscitation is a mainstay in the treatment of patients with sepsis and septic shock and is recommended by the Surviving Sepsis Campaign. Clinicians often site the presence of the co-morbid conditions studied in this paper as justification to not order the recommended 30 cc/kg IVF bolus.

-          The findings in this paper correspond with two prior publications which come to mind suggesting the optimal dosing of IVF for patients sepsis patients is around 30 cc/kg IVF:

o    Liu et al. Ann Am Thorac Soc Vol 10, No 5, pp 466–473, Oct 2013 , demonstrates a “J-Shaped” curve for IVF administration and mortality with inflection points occurring at < 7.5 cc/kg and > 45 cc/kg.

-          Leisman et al. Crit Care Med 2018; 46:189–198 demonstrated that > 50% of patients with CHF and ESRD were “fluid responsive” to an initial fluid bolus in the ER.

Weaknesses:

-          Retrospective study. Can not determine causation.

-          Relatively small number of patients, wide confidence interval for intubation in 72 hours (C.I. = 0.41-1.36)

-          Did not risk stratify patients within disease categories, for example, patients with EF 5% vs 40%

-          Did not include maintenance fluid volume or fluid given by EMS personnel

-          Does not offer explanation as to why some patients received full 30 cc/kg IVF bolus while others did not

Conclusion: The 30 cc/kg IVF bolus recommended by the Surviving Sepsis Campaign does not appear to be associated with higher rates of intubation in high risk patients with sepsis. The presence of co-morbid conditions such as CHF, ESRD and Cirrhosis alone should not dissuade clinicians from ordering the full dose bolus. Clinicians should continue to use additional data points such as point of care ultrasound, laboratory and hemodynamic markers of perfusion to aid in decision making. 

-by John Kazianis, MD , Medical Director AICU

Current Management of HFpEF- ESC

ID Things to Be Grateful For, 2019 Edition

• An Ebola vaccine works! In perhaps no other disease will a vaccine play such a critical role in getting control of an outbreak. This is wonderful, very welcome progress!
• U = U (undetectable equals untransmittable) continues to hold up. Perhaps the most transformative finding in the history of HIV medicine — that people on successful HIV treatment don’t pass the virus on to others sexually — remains a rock-solid fact. I’ve included U = U here before several times, but why not continue to celebrate it?
• HIV incidence in many urban regions in the USA drops. In New York City, for example, 1,917 people were diagnosed in 2018, a 67 percent decline from 2001. Treatment as prevention and PrEP are yielding these impressive results.
• Zika is all but gone. Remember how crazy things were in 2016? Especially for couples who wanted to have children? And for us ID doctors (and primary care and OBs) trying to advise them? Yes, Zika could come back (and likely one day will), but let’s be grateful for our current situation compared to that insane period.
• New antibiotics, some with new mechanisms of action, expand our treatment options. No, they’re not perfect, and some are only incremental advances, or targeted at rare clinical situations — but great anyway to have lefamulin, pretomanid, omadacycline, eravacycline, meropenem-vaborbactam, imipenem-relebactam, cefiderocol (with some confusing data on this last one, still to be sorted out). Now let’s try to fix the economics of antibiotic drug development!
• Additional studies continue to demonstrate the clinical benefit of ID consultation on outcomes. Just a few recent examples — candidemia, sepsis, and long-term outcomes in Staph aureus bacteremia. The parade goes on and on!
• A “Shorter is Better” philosophy about duration of antibiotic therapy moves into clinical practice. And with this updated super list from Dr. Shorter-is-Better himself, Brad Spellberg (https://www.bradspellberg.com/)

• Pragmatic clinical trials in ID give us important new strategies for therapy. The most notable examples in the past year are the POET and OVIVA trials, demonstrating the noninferiority of oral to IV therapy for endocarditis and osteomyelitis. More of these, please!
• The “Ask the Experts” section on the Immunization Action Coalition remains a gold mine of useful information.  I’ve mentioned it before, but that doesn’t mean I can’t still be grateful! Barely a week goes by without my consulting this site.
• Shorter treatment courses for latent TB gain traction. Drug interactions aside, who doesn’t prefer 4 months of rifampin to 9 months of INH? Can 1 month of isoniazid/rifapentine be far behind?
• New guidelines for diagnosis and treatment of Lyme Disease are imminent. The draft guidelines have already been released — final version expected soon.
• Dolutegravir-based regimens are increasingly available globally. In many settings that previously had only efavirenz (first-line) and lopinavir/ritonavir (second line), dolutegravir represents major progress — for both treatment-naive and treatment-experienced patients. It will be important to see how this big change in strategy works out, which is the primary goal of this observational study.

                                                                             by Paul E. Sax, MD-Journal Watch

Precision Therapy in the ICU

An excellent presentation, highlighting the limitations of guidelines:one fits all. This is the main problem of RCT's also (which we base the guidelines on), a heterogeneous population = no external validity .

Strain Imaging ASE

10 Things ICU Specialists Need to Know about New Valvular Procedures in Interventional Cardiology

Many invasive procedures are now performed for valve replacement or repair.  Of significant importance are transcatheter aortic valve replacement (TAVR), transseptal procedures including transcatheter mitral valve repair (TMVR) and transcatheter tricuspid valve repair (TTVR).

Following complications are encountered with these procedures [see article for details]

1.  Rhythm disorders
2.  Pericardial tamponade
3.  Cerebrovascular events
4.  Vascular complications
5.  Myocardial ischemia
6.  Paravalvular leak
7.  Postoperative delirium
8.  Device embolization or clip detachments
9.  Renal failure
10.  Early onset prostatic valve endocarditis

Man's 4th Best Ho$pital

The House of God made a huge impression on me as a  medical resident, and established probably  early a sense of irony and sarcasm in me. Similar to the political works of Kurt Vonnegut ( particularly Slaughterhouse Five) , Samuel Shem brought the same kind of humor to the medical scene.

Finally after 50 years here is the follow up to his masterwork !

Management of life-threatening bleeding in anticoagulated patients.

Book of the Week

SQTS - short QT syndrome

As you you know, I read EKG' on the side ( and any interesting tracings send them my way, please). I read an EKG fir the first time the other day with Short QT < 360 ms . I was aware SQTS is an arrhythmogenic disease associated with paroxysmal atrial and ventricular fibrillation, syncope and sudden cardiac death.
What I didn't know is that the the first one to describe this syndrome is Preben Bjerregaard , originally from Denmark, but moved to the USA in 1989 ( Professor at Washington University in St Louis, Mo until 2012) and discovered the syndrome in 1999.
His website is quite interesting. also there is a nice summary on Life in the Fast Lane.
It is still considered quite rare, but then was amyloid also 50 years ago. The more dangerous genotypes are the ones associate with QT of <320 and <340 ms, respectively.

Therapy is an ICD, but has a lotof problems with over sensing of the large T -wave. Type Ia drugs appear promising therapies

Be on the look-out ! Let me know if you find a tracing 💫

• QTc intervals < 330 ms in males or < 340 ms in females should be considered diagnostic of SQTS
• QTc intervals < 360 ms in males or < 370 ms in females should only be considered diagnostic of SQTS when supported by symptoms or family history

Pain Management in the ICU

Refer to the following  analgo-sedation protocol (PDF) from The London Science Centre

Burnout in HealthCare

Presented by Dr Srinivasan, CMO- Advanced ICU Care

2019 ESC Guidelines for Acute Pulmonary Embolism

The following are key points to remember from the 2019 European Society of Cardiology (ESC) and European Respiratory Society (ERS) Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism (PE):

1. D-dimer cut-offs should be adjusted to age and pretest probability rather than fixed values.
2. Terminology such as “provoked” vs. “unprovoked” PE/venous thromboembolism (VTE) is no longer supported by the guidelines; instead they propose using terms like “reversible risk factor,” “any persistent risk factor,” or “no identifiable risk factor.”
3. A revised risk-adjusted management algorithm is proposed accounting for clinical severity, right ventricular dysfunction, and other comorbidities with emphasis on multidisciplinary teams (Class IIa) and early PE risk stratification.
4. Hemodynamic instability is now clearly defined as presence of cardiac arrest needing resuscitation or obstructive shock or persistent hypotension not caused by other pathologies.
5. Rescue intravenous (IV) thrombolysis is now a Class I recommendation (previously Class IIa), and interventional thrombus removing therapy (catheter-based or surgical) is now a Class IIa (previously Class IIb) recommendation in hemodynamically deteriorating PE.
6. Direct oral anticoagulants (DOACs) are now recommended as first choice anticoagulants over warfarin even in those who are warfarin eligible.
7. A reduced dose of apixaban or rivaroxaban for extended anticoagulation should be considered after the first 6 months of treatment.
8. Edoxaban or rivaroxaban should be considered as an alternative to low molecular weight heparin in patients with cancer, with caution in gastrointestinal cancer due to the increased bleeding risk with DOACs.
9. A dedicated diagnostic algorithm is proposed for suspected PE in pregnancy. Using D-dimer and other clinical prediction rules to rule out PE during pregnancy is now Class IIa recommendation (previously Class IIb). DOACs are not recommended in pregnancy (Class III).
10. Routine follow-up with an integrated inpatient-outpatient care delivery model 3-6 months after as well as referring symptomatic patients with mismatched perfusion defects (on V/Q scan) >3 months post-PE to an expert chronic thromboembolic pulmonary hypertension center is a Class I recommendation.

A Rare Disease Process

Vaping Webinar SCCM

"Unpublished on You Tube" only available via above Link. 

Vaping follow- up Webinar

ACS and Atrial Fibrillation and Triple Anti-coagulation Therapy

The above video is an important clinical topic. We have now much more date on D(N)OAC therapy in patients with combined ACS and Afib. Knowledge of the guidelines, although soon to change is important for safe practice in this population. The first slide shown is very interesting and something that was totally unknown during my postgraduate training: anticoagulation and antiplatelet pathways are intimately connected. An example is the effect of thrombin on PAR receptors and platelet activity. Choice, duration  and combination of treatment are presented in this excellent webinar.

The below webinar is probably of less significance to the Intensivist, but again compared to how we used TEE 10 years ago is somewhat baffling.The presented guidelines for use of TEE are helpful.   

CAP in Adults

2019 IDSA Guidelines for Community Acquired Pneumonia in Adults: To HCAP, we just say fare thee well

Books of the Week

Screening and Treatment for Iron Deficiency in HFrEF with Ferric Carboxymaltose

Clinical practice update on heart failure 2019:pharmacotherapy, procedures, devices andpatient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology Petar M. Seferovic1, Piotr Ponikowski2, Stefan D. Anker3*, Johann Bauersachs4, Ovidiu Chioncel5, John G.F. Cleland6, Rudolf A. de Boer7, Heinz Drexel8, Tuvia Ben Gal9, Loreena Hill10, Tiny Jaarsma11, Ewa A. Jankowska2, Markus S. Anker12, Mitja Lainscak13, Basil S. Lewis14, Theresa McDonagh15, Marco Metra16, Davor Milicic17, Wilfried Mullens18, Massimo F. Piepoli19, Giuseppe Rosano20, Frank Ruschitzka21, Maurizio Volterrani22, Adriaan A. Voors7, Gerasimos Filippatos23, and Andrew J.S. Coats24*


Ferric Carboxymaltose

Anticoagulation in Concomitant Chronic Kidney Disease and Atrial Fibrillation

• The decision to initiate OAT poses a clinical conundrum in patients with coexisting AF and advanced CKD.
• In CKD, several pathophysiological factors result in a progressively increased risk of both ischemic stroke and hemorrhage as renal function declines, irrespective of OAT.
• The limited available data suggests that DOACs should generally be favored over VKAs in view of their probable increased safety and efficacy in CKD, with a lower risk of vascular calcification and anticoagulant-associated nephropathy.
• Until dedicated RCTs are completed to define optimal management, clinical decision-making should be informed by the limited data available, which necessitates individualization and physician-patient collaboration.

Diagnosis and Treatment of Pulmonary Embolism

The recent European Society of Cardiology (ESC) and European Respiratory Society (ERS) Joint release of the Diagnosis and Management of Acute Pulmonary Embolism Guidelines (2019) highlight a number of changes in class level recommendations as compared to the 2014 version, as well as new guideline recommendations. Among these, a Class IIa recommendation for multidisciplinary management of patients means that awareness of the emerging trends in PE management is crucial.

Phillip Green, MD (Columbia University Medical Center) provides an in-depth analysis of Pulmonary Embolus Response Team (PERT) protocols in Contemporary Treatment for Pulmonary Embolism in the CurrentMD platform. 

 Full transcript from this course on the K2P - blog listed in the side bar

Book of the the Week

Ticagrelor- induced bradycardia

By Hasan Shubbarov, AICU : Telemetry Technician  

Brilinta (Ticagrelor), a direct-acting and reversible P2Y₁₂-adenosine diphosphate receptor antagonist, is recommended as a first-line antithrombotic agent in patients with acute coronary syndromes. The superiority of ticagrelor over other P2Y₁₂ antagonists is thought to be mediated in part by pleiotropic properties associated with an increased concentration of adenosine, including cardioprotection, anticoagulant effects, and anti-inflammatory properties. However, these pleiotropic properties can also be responsible for major adverse effects, including electrophysiological consequences. Herein, we describe cyclical sinus bradycardia and atrioventricular (AV) block related to ticagrelor.

Ticagrelor can induce significant bradyarrhythmias. Electrophysiologists should, therefore, be aware of this reversible cause of sinus node dysfunction and AV block in order to manage patients appropriately and avoid unnecessary pacemakers. As this case illustrates, it is possible that the combination of ticagrelor-induced Cheyne-Stokes respiration and bradyarrhythmias can provoke a more severe phenotype consisting of cyclical severe sinus bradycardia with concomitant AV block.

In the setting of an acute coronary syndrome, the differential diagnosis considered included ischemia of the conduction system and ischemia-provoked autonomic dysfunction. However, the time course, with onset of the bradyarrhythmia following ticagrelor loading and rapid recovery upon cessation of therapy, favored the diagnosis of an adverse pharmacologic effect. Bradycardia related to ticagrelor was first described in a phase IIb dose-ranging study, where a post hoc analysis of cardiac arrhythmias revealed an unexpected increased incidence of predominantly asymptomatic ventricular pauses. These findings were corroborated by the prospective PLATO (Platelet Inhibition and Patient Outcomes) trail.

The effect of ticagrelor on sinoatrial and AV nodes is believed to be mediated by an increased tissue concentration of adenosine. Animal experiments and in vitro models demonstrated that ticagrelor interferes with adenosine metabolism, resulting in increased adenosine concentrations via inhibition of adenosine uptake by erythrocytes. This is most likely due to inhibition of sodium-independent equilibrative nucleoside transporters. Consistently, in the clinical realm, ticagrelor has been associated with increased coronary blood flow velocity in patients with acute coronary syndromes, providing a plausible mechanistic explanation for its off-target cardioprotective effects. The adenosine-related hypothesis can also explain the predominance of ticagrelor-associated nocturnal pauses due to an increased local adenosine concentration that enhances vagal-mediated nocturnal bradycardia.

Few reports of clinically significant ticagrelor-related bradycardia requiring drug discontinuation have been published.  Cheyne-Stokes respiration frequently occurs in patients with congestive heart failure and has been associated with exaggerated respiratory heart rate variations. Emerging reports suggest that ticagrelor may itself induce central sleep apnea and Cheyne-Stokes respiration. The pathophysiological explanation remains unclear. Proposed mechanisms include antagonism of microglial P2Y12 receptors and effects on pulmonary C fibers, either as a result of increased adenosine tissue levels or because of putative P2Y12 receptors on pulmonary C fibers.

Conclusion. Extreme caution and close monitoring for development of heart block are needed after initiation of ticagrelor, especially in patients with preexisting conduction defect or on AV nodal blocking agent. Beta blockers may not be the only reason for such cases of symptomatic bradycardia or high grade AV block. Ticagrelor should be considered as the possible offending agent. Other P2Y12 platelet receptor inhibitors such as clopidogrel or prasugrel are suitable alternatives if the patient is at risk for development of a potentially life threatening heart block.

Vaping-Related Lung Injury

The number of people who have developed a lung injury after vaping has hit 1080, the CDC reported on Thursday. In the past week, the number of confirmed and probable cases increased by 275.

The number of fatalities increased from 12 to 18. Additional deaths are under investigation. Health officials said that the epidemic is continuing at a brisk pace and doesn't show signs of slowing. Most, but not all, patients have used products containing tetrahydrocannabinol (THC).

"CDC recommends people refrain from using e-cigarettes and vaping products, particularly those containing THC ... particularly those bought off the street," said CDC principal deputy director Dr. Anne Schuchat.

In preliminary tests, concentrations of THC in affected patients' vaping products have been between 14% and 76%.

This an excellent presentation from the CDC: Outbreak of Lung Injury Associated withE-cigarette Product Use or Vaping

NEJM E-Cigarettes and Vaping-Related Disease Publications

Some CT chest examples on presentation:

ICD Indication for IHD to Prevent SCD

Slide set with Summary 2017 ACC/AHA guidelines


2017 AHA/ACC/HRS Guideline for Managementof Patients With Ventricular Arrhythmias andthe Prevention of Sudden Cardiac Death- these are all 120 pages !

Will This Patient Be Difficult to Intubate?

A previously healthy 27-year-old woman was scheduled for elective cholecystectomy. Examination of her airway demonstrated a modified Mallampati score of 2; however, she was unable to bite her upper lip with her lower incisors.

Is she a difficult airway ? Which test has the best +LR?

As a non- anesthesiologist , I definitely learned something new here. The widely used modified Mallampati score (>or equal then 3) had only a +LR= 4.1. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test, +LR = 14

In this systematic review in the September JAMA LN issue, several physical findings increased the likelihood of difficult intubation. The best predictors were an inability to bite the upper lip with the lower incisors, a short hyomental distance, retrognathia, or a combination of findings based on the Wilson score. No risk factor or physical finding consistently ruled out a potentially difficult intubation.

.
 An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient

Silent left ventricular apical ballooning and Tako-tsubo cardiomyopathy and it's prevalence in the ICU

I have published already on Tako - tsubo cardiomyopathy (LVAB or TCC ) . If you go in the search engine you will find that post  , it was presented as a MC question.( Differentiating between the three morphological types.

I know, I may be boring you to death, but my suspicion after looking at multiple echos of various institutions, I was surprised on the high prevalence of this disorde , without its classic risk factors, consistent with what's being reported in the literature

Recent studies have reported a variable, but surprisingly high,incidence of undiagnosed LVAB in some intensive care settings. An incidence of 28% in medical ICU patients was reported in a South Korean study that screened 92 consecutive patients by echocardiography and 5.6% of the medical ICU patients who required echocardiography for clinical and hemodynamic reasons. Harm was caused by using inotropes with worse outcomes.

A more recent study in  the September issue of  The European Society Cardiology Heart Failure .the incidence of silent LVAB suggestive of TCC was substantially lower in this study than recently reported in other international ICU settings .A total of 116 patients were enrolled of whom four had LVAB (3.5%,95% confidence interval 0.9–8.6%). The authors conclusion was: a larger, multi-centre study, prospectively screening for LVAB may help understand any variation between centers and regions, with important implications for ICU management.

I think this number is probably to low and as shown on the diagram,  so many risk factors now are identified that most likely none of the studied population groups are similar in risk factor pofile;  they will have a different pre- test probabilities for risk of LVAB. Also regional /geographic /ethnic factors may play a role.It's a little bit of a similar story with ATTR- amyloidosis,  which is grossly under diagnosed, and patient are not being treated with new drugs directed at transthyretin tetramer folding and deposition in the myocardium.

Nevertheless, when I was still doing bedside medicine no patient came in the ICU/CCU  without getting an immediate echocardiogram ( complete study with TDI) ,  particularly if there was any evidence of hemodynamic instability. It's truely not all about fluids and vaspressors only.

We know there is a substantial population we will harm with blindly throwing them on vasopressors/inotropes as discussed above  . One specific example  were excessive doses of epinephrine causes harm, for  example is the Kounis Syndrome  ( Kounis syndrome and Epinephrine; the ATAK Complex )  ATAK constitutes a challenging contemporary complex in anaphylaxis associated with TCC. It is vital to use epinephrine correctly and monitor vital signs and ECGs for patients with acute anaphylaxis.(see Kounis syndrome link above)

It also makes me wonder if high and repeated doses of epinephrine are truly the right therapy for example in PEA arrest  or could they be more harmful ?

Reference images :Current state of knowledge on Tako-tsubo syndrome: a position statement from the task force on Takotsubo syndrome of the Heart Failure Association of the European Society of
Cardiology

Cardiac amyloidosis increasingly common in US

New research suggests the incidence of cardiac amyloidosis in the U.S. is trending up, bringing with it high rates of morbidity and mortality.

Scientists have long assumed the instance of cardiac amyloidosis—the deposition and buildup of immunoglobulin light chains (AL) or transthyretin (ATTR) in heart tissue—is on the rise, Brett W. Sperry, MD, and colleagues wrote in the American Journal of Cardiology. Recent years have seen a rise in awareness of the disease, more novel treatment options and improved noninvasive diagnostic imaging modalities, but the hospitalization trends for amyloidosis remain unclear, especially for AL type.

Sperry, of the Mid America Heart Institute at Saint Luke’s Hospital and University of Missouri-Kansas City in Kansas City, Mo., combed National Inpatient Sample data with his team to identify 156,914 patients hospitalized with amyloidosis between 2005 and 2014. Patients were on average 70 years old and more often white men, and 34.7% of the pool presented with concomitant heart failure.

The researchers noted the overall number of hospital admissions in patients with amyloidosis more than doubled during the study period—from 9,296 in 2005 to 21,740 in 2014. During the peak in 2014, 62 of every 100,000 hospital admissions was related to amyloidosis.

“The explanation for the more than doubling of the rate of hospitalization in those with amyloidosis is likely multifaceted,” Sperry et al. wrote in AJC. “One possibility is that the incidence and prevalence of amyloidosis are increasing due to a growing awareness of the disease. Alternatively, the aging of the population may contribute to these observed trends.”

Over time, patients admitted with amyloidosis tended to be older and have more medical comorbidities, the authors said. They also had longer lengths of stay than those without the disease (7.5 vs. 6.2 days), were less likely to be discharged home (43.6% vs. 48.7%) and were more likely to die while hospitalized (7.4% vs. 4.9%). Patients with concomitant heart failure fared worse in terms of mortality, too.

Sperry and colleagues said it’s impossible to differentiate between AL and ATTR amyloidosis in the NIS, but said it seems likely that ATTR is contributing more to the rise in amyloidosis given the increase in older and black patients over time with a decrease in concomitant multiple myeloma. AL amyloidosis diagnoses, on the other hand, have remained relatively stable for the past seven decades while prevalence has increased, likely because older patients are living longer.

Though their study was inherently limited by the possibility of NIS inaccuracies and human error, the authors said their study was able to shed light on some of the lesser-known characteristics of amyloidosis in the U.S.

“Given the increasing prevalence of hospitalizations in patients with amyloidosis, enhanced diagnostic and treatment options have the potential to improve care for a growing population of patients,” they wrote.

I will comment that almost every other shift , I am suspicious that I see at least once a patient that could have ATTR-wt amyloid  ( far more common then AL-amyloid) 

Use of Medication for Cardiovascular Disease During Pregnancy

CV Medications in Pregnancy

Table for Quick Review, I posted this article earlier in the year but not the Central Illustration 

Cardiovascular disease complicating pregnancy is rising in prevalence secondary to advanced maternal age, cardiovascular risk factors, and the successful management of congenital heart disease conditions. The physiological changes of pregnancy may alter drug properties affecting both mother and fetus. Familiarity with both physiological and pharmacological attributes is key for the successful management of pregnant women with cardiac disease. This review summarizes the published data, available guidelines, and recommendations for use of cardiovascular medications during pregnancy. Care of the pregnant woman with cardiovascular disease requires a multidisciplinary team approach with members from cardiology, maternal fetal medicine, anesthesia, and nursing.

Summary:

1. Labetalol and methyldopa are the agents of choice in treating pregnant patients with hypertension.
2. Although all antihypertensive agents cross the placenta, methyldopa and labetalol appear to be the safest antihypertensive agents in pregnant women.
3. ACE inhibitors (such as lisinopril), angiotensin receptor blockers (such as losartan), spironolactone, and direct renin inhibitors (aliskiren) are teratogenic and are therefore contraindicated during pregnancy. During the first trimester, these agents can cause central nervous system and cardiovascular malformations in the fetus. Second-trimester exposure can cause developmental malformations of the kidneys and genitourinary system.
4. A 2013 guideline published by the American College of Obstetricians and Gynecologists made a strong recommendation for initiation of pharmacologic therapy for pregnant women with persistent chronic hypertension at a systolic blood pressure of 160 mm Hg or higher or a diastolic blood pressure of 105 mm Hg or higher. However, other guidelines, including one from the European Society of Cardiology, continue to recommend initiation of pharmacologic therapy at a systolic blood pressure of 150 mm Hg or higher or a diastolic blood pressure of 95 mm Hg or higher in women without symptoms or evidence of end-organ damage due to hypertension

ESC Guidelines on the management ofcardiovascular diseases during pregnancy