Hemodynamic effects of angiotensin inhibitors in elderly hypertensives undergoing total knee arthroplasty under regional anesthesia.

The aim was to investigate the association between continuing angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARB) with postinduction hypotension and vasoactive drug use in elderly orthopedic surgery patients under regional anesthesia. Retrospective design consisted of 114 patients (mean age 66) undergoing elective total knee arthroplasty, including 84 patients with chronic hypertension, and they were divided as group I (n = 37), ACEI/ARB continued; group II (n = 23), ACEI/ARB withdrawn; group III (n = 24), β-blocker/calcium channel blocker continued; and group IV (n = 30), without hypertension (control). Primary end points are systolic blood pressures (SBPs) and mean arterial blood pressures (MAPs) at 0, 30, 60, and 90 minutes postinduction, incidence of hypotension (SBP <85 mm Hg), and ephedrine requirements.

First time myocardial infarction in a rheumatic patient after elective arthroplasty.

The management of perioperative cardiovascular risk in patients with rheumatoid arthritis (RA) is challenging due to the independent contribution to risk by high grade inflammatory mechanisms and the underestimation of risk by traditional cardiac risk factors alone. RA is associated with accelerated rates of subclinical atherosclerosis and markedly higher rates of both myocardial infarction and sudden cardiac death over non-RA controls. There is an absence of prospectively validated perioperative coronary heart disease (CHD) risk assessment tools for this unique patient population and available guidelines may fail to identify those patients most at risk.

Cardiac Arrest during Total Hip Arthroplasty in a Patient on an Angiotensin Receptor Antagonist.

Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor antagonists (ARA) are effective and well-tolerated first-line drugs in the therapy of hypertension and, therefore, are frequently encountered in the perioperative setting. Hemodynamic compensation for volume depletion seen in the perioperative period is normally mediated by the renin-angiotensin system, which is blocked by ACEI/ARA. These drugs may contribute to severe hypotension during anesthesia induction and may have contributed to the cardiac arrest seen in this patient.

Contrast-enhanced anatomic imaging as compared to contrast-enhanced tissue characterization for detection of left ventricular thrombus.

Objectives: This study sought to compare contrast-enhanced anatomic imaging and contrast-enhanced tissue characterization (delayed-enhancement cardiac magnetic resonance [DE-CMR]) for left ventricular (LV) thrombus detection.

Background: Contrast echocardiography (echo) detects LV thrombus based on anatomic appearance, whereas DE-CMR imaging detects thrombus based on tissue characteristics. Although DE-CMR has been validated as an accurate technique for thrombus, its utility compared with contrast echo is unknown.

Prognostic value of multiple biomarkers in American Indians free of clinically overt cardiovascular disease (from the Strong Heart Study).

Several biomarkers have been documented, singly or jointly, to improve risk prediction, but the extent to which they improve prediction-model performance in populations with high prevalences of obesity and diabetes has not been specifically examined. The aim of this study was to evaluate the ability of various biomarkers to improve prediction-model performance for death and major cardiovascular disease (CVD) events in a high-risk population. The relations of 6 biomarkers with outcomes were examined in 823 American Indians free of prevalent CVD or renal insufficiency, as were their contributions to risk prediction.

A clinical and biochemical critical pathway for the evaluation of patients with suspected acute congestive heart failure: The ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) algorithm.

Dyspnea is a primary clinical manifestation of acute congestive heart failure (CHF) among patients presenting to the emergency department (ED). Unfortunately, other critical illnesses, including acute coronary syndromes, pulmonary embolism, chronic obstructive pulmonary disease, and pneumonia, may present with clinical symptoms and signs similar to acute CHF. N-terminal pro-brain natriuretic peptide (NT-proBNP) has proven to be a powerful tool in the diagnostic assessment of dyspnea as a result of its ability to confirm or exclude the presence of acute CHF.

Usefulness of aminoterminal pro-brain natriuretic peptide testing for the diagnostic and prognostic evaluation of dyspneic patients with diabetes mellitus seen in the emergency department (from the PRIDE Study).

Despite widespread testing, the utility of aminoterminal pro-brain natriuretic peptide (NT-pro-BNP) for diagnosis or risk assessment in patients with diabetes mellitus (DM) in the emergency department (ED) remains unclear. NT-pro-BNP was measured in subjects with dyspnea in the ED. A final diagnosis of acute heart failure (HF) was determined by blinded study physicians using all available hospital records.

Clinical utility of delayed-contrast computed tomography for tissue characterization of cardiac thrombus.

Among patients that present with cardiac masses, thrombus is an important diagnostic consideration that affects both clinical management and prognosis. Although thrombus can occasionally be difficult to diagnose using structural criteria alone, it can be distinguished from other structures according to tissue characteristics. Because thrombus is inherently avascular, absence of contrast uptake was used as a highly specific identifying feature.

Neither race nor gender influences the usefulness of amino-terminal pro-brain natriuretic peptide testing in dyspneic subjects: a ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) substudy.

Background: Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is useful for the diagnosis and exclusion of congestive heart failure (HF). Little is known about the effect of race on NT-proBNP concentrations. Also, NT-proBNP levels may be higher in apparently well women, but the effect of gender on NT-proBNP concentrations in dyspneic patients is not known.

Ventricular hypertrophy and hypertension: prognostic elements and implications for management.

Left ventricular hypertrophy (LVH) is a strong, independent predictor of cardiovascular events and all-cause mortality. Patients with LVH are at increased risk for stroke, coronary heart disease, congestive heart failure, and sudden cardiac death. Hypertension is a major influence on the development of LVH.

NT-proBNP levels, echocardiographic findings, and outcomes in breathless patients: results from the ProBNP Investigation of Dyspnoea in the Emergency Department (PRIDE) echocardiographic substudy.

Aims: The objective of this study was to determine the integrative utility of measuring plasma NT-proBNP levels with echocardiography in the evaluation of dyspnoeic patients.

Methods And Results: Of 599 emergency department patients enrolled in a clinical study of NT-proBNP at a tertiary-care hospital, 134 (22%) had echocardiographic results available for analysis. Echocardiographic parameters correlating with NT-proBNP levels were determined using multivariable linear-regression analysis.

Utility of amino-terminal pro-brain natriuretic peptide testing for prediction of 1-year mortality in patients with dyspnea treated in the emergency department.

Background: Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is useful for diagnosis and triage of patients with dyspnea, but its role for predicting outcomes in such patients remains undefined.

Methods: A total of 599 breathless patients treated in the emergency department were prospectively enrolled, and a sample of blood was obtained for NT-proBNP measurements. After 1 year, the vital status of each patient was ascertained, and the association between NT-proBNP values at presentation and mortality was assessed.

Renal function, congestive heart failure, and amino-terminal pro-brain natriuretic peptide measurement: results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Study.

Unlabelled: The relationship between renal insufficiency and amino-terminal pro-brain natriuretic peptide (NT-proBNP) levels remains unclear. We examined this relationship in the context of patients who presented to the emergency department of an urban tertiary care medical center with dyspnea. Even in the presence of renal insufficiency, NT-proBNP remained a valuable tool for the diagnosis of acute congestive heart failure and it provides important prognostic information.

A validated clinical and biochemical score for the diagnosis of acute heart failure: the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Acute Heart Failure Score.

Background: No method integrating amino-terminal pro-brain natriuretic peptide (NT-proBNP) testing with clinical assessment for the evaluation of patients with suspected acute heart failure (HF) has been described.

Methods: Amino-terminal pro-brain natriuretic peptide results and clinical factors from 599 patients with dyspnea were analyzed. The beta coefficients of the 8 independent predictors of HF were used to assign a weighted integeric score for predictor.

Severe ataxia caused by amiodarone.

Neurologic toxicity is an infrequently reported and under-recognized consequence of amiodarone, symptoms of which may include tremor, peripheral sensorimotor neuropathy, proximal weakness, and ataxia. The investigators report the rapid and complete remission of 4 months of progressively debilitating ataxia with the discontinuation of small-dose amiodarone in an elderly woman with hypertrophic obstructive cardiomyopathy and paroxysmal atrial fibrillation. Despite the long half-life of amiodarone, her symptoms began to reduce after several days, and she was walking without assistance within 1 week.

Effect of body mass index on natriuretic peptide levels in patients with acute congestive heart failure: a ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) substudy.

Background: Obesity is associated with lower B-type natriuretic peptide (BNP) levels in healthy individuals and patients with chronic congestive heart failure (CHF). Neither the mechanism of natriuretic peptide suppression in the obese patient nor whether obesity affects natriuretic peptide levels among patients with acute CHF is known.

Methods: The associations of amino-terminal pro-BNP (NT-proBNP), BNP, and body mass index (BMI) were examined in 204 subjects with acute CHF.

The effects of ejection fraction on N-terminal ProBNP and BNP levels in patients with acute CHF: analysis from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) study.

Background: Limited data exist regarding the impact of left ventricular ejection fraction (LVEF) on N-terminal pro-brain natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP) levels in patients with acute congestive heart failure (CHF).

Methods And Results: LVEF data were analyzed for 153 subjects with acute CHF. LVEF > or =50% was defined as non-systolic CHF (NS-CHF); LVEF >50% was defined as systolic CHF (S-CHF).

The N-terminal Pro-BNP investigation of dyspnea in the emergency department (PRIDE) study.

The utility of aminoterminal pro-brain natriuretic peptide (NT-proBNP) testing in the emergency department to rule out acute congestive heart failure (CHF) and the optimal cutpoints for this use are not established. We conducted a prospective study of 600 patients who presented in the emergency department with dyspnea. The clinical diagnosis of acute CHF was determined by study physicians who were blinded to NT-proBNP results.