DOCSLIB.ORG

Standardisation and Hyperaemia

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Standardisation and Hyperaemia FFR Standardisation and Hyperaemia aalst.be - www.cardio Bernard De Bruyne Cardiovascular Center Aalst Belgium ETP April 24-26, 2014 Hyperemic Stimuli Why ? How ? aalst.be FAQ ! - www.cardio Bernard De Bruyne, MD, PhD Cardiovascular Center Aalst OLV-Clinic Aalst, Belgium ETP April 24-26, 2014 Why? 1. General concept of stress test (as opposed to “rest test”) 2. Standardized measurements (as opposed to “moving target”) aalst.be 3. All clinical outcome data are based on hyperemic data - www.cardio ETP April 24-26, 2014 General concept of stress test Mild Aortic Stenosis Rest aalst.be - www.cardio P = 17 mm Hg ETP April 24-26, 2014 General concept of stress test Mild Aortic Stenosis Rest Dobutamine CO 4.8 L/min 40 µg/kg/min CO 8.1 L/min aalst.be - www.cardio P = 17 mm Hg P = 21 mm Hg ETP April 24-26, 2014 General concept of stress test Aortic Stenosis Cardiac output 3.8 L.min-1 Cardiac output 8.6 L.min-1 Aortic Gradient 26 mm Hg Aortic Gradient 58 mm Hg Aortic Valve Area 0.77 cm² Aortic Valve Area 1.1 cm² aalst.be - www.cardio ETP April 24-26, 2014 General concept of stress test Diabetes Oral Glucose Tolerance Test: 75 g of sugar to be drunk within 5 minutes Mg/dL Mg/dL 200 Normal 200 Diabetes 180 180 160 160 140 140 120 120 aalst.be - 100 100 80 80 60 60 www.cardio 40 40 20 20 0 0 Fasting 2 hours 4 Hours Fasting 2 hours 4 Hours ETP April 24-26, 2014 General concept of stress test The Wind Tunnel aalst.be - www.cardio ETP April 24-26, 2014 Why? 1. General concept of stress test (as opposed to “rest test”) 2. Standardized measurements (as opposed to “moving target”) aalst.be 3. All clinical outcome data are based on hyperemic data (FFR) - www.cardio ETP April 24-26, 2014 The Control of Resting Myocardial Blood Flow Neuro-humoral Metabolic factors α1 α2 factors Adenosine Noradrenaline A Adrenaline β1 β 2 2 NO PGI EDHF 2 PO α2 2 Acethylcholine M M + + PCO2, H , K TXA2 TXA2 NOEndothelium ETA ET 5-HT PGI 2 ETB Arterial Pressure 5-HT EDHF ETB Coronary pressure P2 H AT1 Angiotensine II RAP, LVDP and Pf=0 B2 1 P2 NO PGI2 EDHF H2 H1 Histamine Systolic compression aalst.be Diastolic compression Bradykinine - Physical Endo- and paracrine factors factors www.cardio The “resting state” in biology is wishful thinking of biologists „Rest‟ is almost never „steady state‟ ETP April 24-26, 2014 The Control of Resting Myocardial Blood Flow aalst.be - www.cardio ETP April 24-26, 2014 Why? 1. General concept of stress test (as opposed to “rest test”) 2. Standardized measurements (as opposed to “moving target”) 3. All clinical outcome data are based on hyperemic data (FFR) aalst.be - www.cardio ETP April 24-26, 2014 How? aalst.be “Keep it Simple and Standardized” - www.cardio The KISS principle ETP April 24-26, 2014 Maximal Vasodilation Epicardial Microvasculature = Conductance = Resistance Arteries > 550 µ Arteries < 550 µ aalst.be - www.cardio Vasospasm Autoregulation ETP April 24-26, 2014 Maximal Vasodilation 1. Nitrates Epicardial arteries 2. Adenosine Microvasculature aalst.be IV: 140 µg/kg/min - www.cardio IC: 100 – 200 µg in bolus ETP April 24-26, 2014 Maximal Vasodilation 1. Nitrates Epicardial arteries 2. Adenosine Microvasculature aalst.be 3. Papaverine inhibition of phosphodiesterase cyclic adenosine MP ↑ - 4. Regadenoson precursor of adenosine 5. Apadenoson precursor of adenosine 6. Binodenoson precursor of adenosine 7. Nitroprusside NO pathways direct non-selective vasodilator www.cardio 8. Nicorandil ↑ guanylate cyclase to increase formation of cyclic GMP - 9. Dopamine ß1 agonist ↑ O2 consumption adenosine ↑ 10. Exercise Adren stimulation ↑ O2 consumption Adenosine ↑ 11. Coronary occlusion Ischemia release of adenosine ETP April 24-26, 2014 Adenosine: Mechanisms of Action Target organs Receptors (A1, A2A, A2B, A3) - Coronary arteriolar smooth muscle cells A 2A - Renal arteries (organ level) A1 - Peripheral and central nervous system A1 A2A - Myocardium A3 - Cardiac Conduction system A1 - Respiratory tract A1 - Fibroblast, Adipocytes, Immune System A 2B ADO 40 µg bolus in Renal Artery ADO 40 µg bolus in LAD aalst.be - www.cardio ETP April 24-26, 2014 Half Life = 4 to 10 s Maximal Vasodilation 1. Nitrates Epicardial arteries 2. Adenosine Microvasculature aalst.be IV: 140 µg/kg/min - www.cardio IC: 100 – 200 µg in bolus ETP April 24-26, 2014 Adenosine IV aalst.be - www.cardio ETP April 24-26, 2014 Specificities of IV Adenosine (140 µg/kg/min) 1. Preferred route when a pressure pull back is needed 2. Induces a brief increase in systemic pressure followed by a decrease in systemic pressure by 10-20% 3. Is almost uniformly accompanied by a burning aalst.be - sensation www.cardio 4. Fluctuation of the Pd/Pa ratio are observed in some cases 5. A-V blocks are relatively frequent, always transient ETP April 24-26, 2014 Adenosine IV 140 µg/kg/min STOP aalst.be - www.cardio ETP April 24-26, 2014 FAQ Useful to increase the dose of IV ado > 140 µg/kg/min ? NO aalst.be - www.cardio ETP April 24-26, 2014 Increasing the dose above 140 µg/kg/min decreases systematic BP and increases the thoracic pain aalst.be - www.cardio ETP April 24-26, 2014 Adenosine IC aalst.be - www.cardio ETP April 24-26, 2014 Specificities of IC Adenosine (100-200 µg) 1. Can be used in the vast majority of lesions 2. Short half live 3. Rare AV blocks, always transient aalst.be - 4. Extremely reproducible: do it twice or more! www.cardio ETP April 24-26, 2014 Adenosine ic dose-response curve aalst.be - www.cardio ETP April 24-26, 2014 Adenosine ic dose-response curve aalst.be - www.cardio ETP April 24-26, 2014 IC Adenosine ... Not that shortlasting aalst.be - www.cardio 12 beats ETP April 24-26, 2014 aalst.be - www.cardio ETP April 24-26, 2014 Specificities of IC Adenosine (100-200 µg) 1. Can be used in the vast majority of lesions 2. Short half live 3. Rare AV blocks, always transient aalst.be - 4. Extremely reproducible: do it twice (or more!) www.cardio ETP April 24-26, 2014 IC Adenosine: reproducible but shortlasting ADO IC 1 ADO IC 2 ADO IC 3 aalst.be - www.cardio FFR = 0.53 FFR = 0.53 FFR = 0.54 ETP April 24-26, 2014 Regadenosone aalst.be IV peripheral - www.cardio ETP April 24-26, 2014 Regadenoson ( = Rapiscan ® ) Regadenoson as single peripheral i.v. bolus 400 µg • maximum hyperemia within 60 sec and lasting for aalst.be - at least 30 seconds (sufficient for pull-back recording) • can be safely repeated after 10 min www.cardio • hyperemia completely comparable to i.v. adenosine ideal in radial procedures or ad-hoc FFR ETP April 24-26, 2014 Van Nunen et al, TCT 2013 Regadenoson vs Adenosine (N=100) aalst.be - www.cardio • Mean Difference 0.00 ± 0.01 ETP April 24-26, 2014 Van Nunen et al, TCT 2013 Quality of the Pressure Recordings • Recording of 12 beats steady state at rest • Very short (1-2 s) injections of ado • Total recording of 45-60 s aalst.be - www.cardio ETP April 24-26, 2014 aalst.be - www.cardio ETP April 24-26, 2014 Tips and Tricks Full Scale aalst.be - www.cardio ± 60 s ETP April 24-26, 2014 Tips and Tricks aalst.be - www.cardio ETP April 24-26, 2014 aalst.be - www.cardio Rest or Hyperemia ? ETP April 24-26, 2014 aalst.be - www.cardio ETP April 24-26, 2014 aalst.be - www.cardio 0.65 0.64 ETP April 24-26, 2014 When Pd/Pa at rest > 0.90, hyperemia ? aalst.be - www.cardio Pd/Pa = 0.96 FFR = 0.62 ETP April 24-26, 2014 aalst.be - www.cardio ETP April 24-26, 2014 Conclusive Remarks 1. Hyperemia is mandatory to “interrogate” a lesion properly 2. Can be obtained very easily, safely, cheaply, ... aalst.be - 3. Provided it is standardized in each laboratory www.cardio ETP April 24-26, 2014 FAQ When Pd/Pa at rest > 0.90, do we have to induce hyperemia ? When Pd/Pa at rest < 0.80, do we have to induce hyperemia ? Useful to increase the dose of IV ado > 140 µg/kg/min ? Useful to increase the dose of IC ado > 200 µg (bolus) ? Is the burning sensation related to ischemia ? aalst.be Are some patients resistant to Adenosine ? - Can Papaverine be used instead of Adenosine ? Is hyperemia expensive ? www.cardio What to do with radial procedures ? Interference with some medications ? Is adenosine contraindicated in patients with lung disease? ETP April 24-26, 2014 FAQ When Pd/Pa at rest > 0.90, do we have to induce hyperemia ? YES aalst.be - www.cardio Pd/Pa = 0.96 FFR = 0.62 ETP April 24-26, 2014 FAQ When Pd/Pa at rest < 0.80, do we have to induce hyperemia ? aalst.be - www.cardio ETP April 24-26, 2014 When Pd/Pa at rest < 0.80, do we have to induce hyperemia ? aalst.be - www.cardio Pd/Pa = 0.56 FFR = 0.42 ETP April 24-26, 2014 FAQ Useful to increase the dose of IV ado > 140 µg/kg/min ? NO aalst.be - www.cardio ETP April 24-26, 2014 Increasing the dose above 140 µg/kg/min decreases systematic BP and increases the thoracic pain aalst.be - www.cardio ETP April 24-26, 2014 FAQ Useful to increase the dose of IC ado > 200 µg (bolus) ? Blood Pressure Pd / Pa aalst.be - N=46 www.cardio 720 µg decreases Pd/Pa a bit further w/o any decrease in BP, any increase in HR and no heart blocks ???? ETP April 24-26, 2014 De Luca et al JACC Interv 2011 FAQ Is the burning sensation related to ischemia ? NO Adenosine is an algesic substance which stimulates the aalst.be same nerves than those resposnsible for angina ..
Load more

Recommended publications
  • Effects of Hyperaemia on Left Ventricular Longitudinal Strain In
    Neth Heart J https://doi.org/10.1007/s12471-017-1071-3 ORIGINAL ARTICLE Effects of hyperaemia on left ventricular longitudinal strain in patients with suspected coronary artery disease A first-pass stress perfusion cardiovascular magnetic resonance imaging study P. G a r g 1 ·R.Aziz1 ·T.AlMusa1 ·D.P.Ripley1 · P.Haaf1 ·J.R.J.Foley1 ·P.P.Swoboda1 ·G.J.Fent1 ·L.E.Dobson1 · J. P.Greenwood1 ·S.Plein1 © The Author(s) 2018. This article is an open access publication. Abstract Aims Myocardial perfusion imaging during hyperaemic stress is commonly used to detect coronary artery disease. The aim of this study was to investigate the relationship between left ventricular global longitudinal strain (GLS), strain rate (GLSR), myocardial early (E’) and late diastolic velocities (A’) with adenosine stress first-pass perfusion cardiovascular magnetic resonance (CMR) imaging. Methods and results 44 patients met the inclusion criteria and underwent CMR imaging. The CMR imaging proto- col included: rest/stress horizontal long-axis (HLA) cine, rest/stress first-pass adenosine perfusion and late gadolinium enhancement imaging. Rest and stress HLA cine CMR images were analysed using feature-tracking software for the assessment of myocardial deformation. The presence of perfusion defects was scored on a binomial scale. In patients with hyperaemia-induced perfusion defects, rest global longitudinal strain GLS (–16.9 ± 3.7 vs. –19.6 ± 3.4; p-value = 0.02), E’ (–86 ± 22 vs. –109 ± 38; p-value = 0.02), GLSR (69 ± 31 vs. 93 ± 38; p-value = 0.01) and stress GLS (–16.5 ± 4 vs. –21 ± 3.1; p < 0.001) were significantly reduced when compared with patients with no perfusion defects.
    [Show full text]
  • Mechanisms of Exertional Angina in Patients with Normal Coronary Arteries
    CLINICAL 10.7861/clinmed.20-2-s44 Mechanisms of exertional angina in patients with normal coronary arteries Authors: Haseeb Rahman,A Ozan Demir,A Matthew Ryan,A Hannah McConkey,A Howard Ellis,A Cian Scannell,A Amedeo Chiribiri,A Andrew WebbA and Divaka PereraA Background was defined as hyperaemic endo/epi<1.0.8 Myocardial perfusion reserve (MPR) was calculated as hyperaemic myocardial blood Forty per cent of patients undergoing angiography to investigate flow / resting myocardial blood flow.9 Patients were classified exertional chest pain have normal coronary arteries. While as having MVD if CFR<2.5 and controls if CFR≥2.5, with described for nearly half a century, this condition has remained researchers blinded to the classification.10 a mechanistic enigma.1–2 Diminished coronary blood flow augmentation to a pharmacological vasodilator, or coronary microvascular dysfunction (MVD), portends a greater risk Results 3–4 of major adverse cardiovascular events. However, patients A total of 95 patients were enrolled (57±10 years, 81% report symptoms during physical exercise, and the response women); 52 were classified as having MVD and 43 as controls. to pharmacological ‘stress’ and physical exercise differ in Microvascular resistance (MR) and CBF during peak exercise 5 the healthy heart. Moreover, it is unclear whether MVD is were similar in MVD and controls (4.5±1.6 vs 4.7±1.6 mmHg/ confined to the coronary circulation or a generalised disorder cm/s and 30±10 vs 27±8 cm/s; p=0.68 and p=0.15). However, in myocardial and systemic blood flow during stress.
    [Show full text]
  • Altered Mental Status Predicts Mortality in Cardiogenic Shock – Results From
    ACC0010.1177/2048872617702505European Heart Journal: Acute Cardiovascular CareKataja et al. 702505research-article2017 EUROPEAN SOCIETY OF Original scientific paper CARDIOLOGY ® European Heart Journal: Acute Cardiovascular Care 2018, Vol. 7(1) 38 –44 Altered mental status predicts © The European Society of Cardiology 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav mortality in cardiogenic shock – https://doi.org/10.1177/2048872617702505DOI: 10.1177/2048872617702505 results from the CardShock study journals.sagepub.com/home/acc Anu Kataja1, Tuukka Tarvasmäki1, Johan Lassus2, Lars Køber3, Alessandro Sionis4, Jindrich Spinar5, John Parissis6, Valentina Carubelli7, Jose Cardoso8, Marek Banaszewski9, Rossella Marino10, Markku S Nieminen2, Alexandre Mebazaa11 and Veli-Pekka Harjola1 Abstract Background: Altered mental status is among the signs of hypoperfusion in cardiogenic shock, the most severe form of acute heart failure. The aim of this study was to investigate the prevalence of altered mental status, to identify factors associating with it, and to assess the prognostic significance of altered mental status in cardiogenic shock. Methods: Mental status was assessed at presentation of shock in 215 adult cardiogenic shock patients in a multinational, prospective, observational study. Clinical picture, biochemical variables, and short-term mortality were compared between patients presenting with altered and normal mental status. Results: Altered mental status was detected in 147 (68%) patients, whereas 68 (32%) patients had normal mental status. Patients with altered mental status were older (68 vs. 64 years, p=0.04) and more likely to have an acute coronary syndrome than those with normal mental status (85% vs. 74%, p=0.04). Altered mental status was associated with lower systolic blood pressure (76 vs.
    [Show full text]
  • The Diving Response in Man, Rat and Echidna
    t('1;'7> THE DIVING RESPONSE IN MAI{, R,AT AÀTD ECHIDNA A TTIESIS Submitted tor the degree of DOCTOR OF I,IEDICINE of The llniversitg of Adelaìde, South AusttaTía bg BRETT ÀùIDREW GOODEN, M.B. rB.S. L97L DECLARATION AIÛD ACKNOIÍLEDGEMENTS I declare that this thesis is of my ovJn composition and that it is a record of original work conducted during the years 19681 1969, I97O a¡¡d I97I in the Department of Human Physiology and Pharmacolog¡¡, University of Adetaide. The work described herein has not been sr¡buritted for any other degree, award or diploma. I wish to record my gratitude to Professor R. F. Itlhelan for his invaluable guidance and encouragement duríng this work. I record my gratitude to Dr M. L. Augee, Mr L. B. Campbell, Dr R. W. Elsner, Mr J. D. Horowitz, Vlt R. G. Lehrnanr Mr J. Plm, Dr S. M. Robinson and Dr P. R. !{ilson with whom I have had the privilege of working during various stages of these investigations. I would also like to thank Dr D. B. Frewin, Dr D. H. LeMessurier and Dr J. A. Vlalsh for their interest in the work, Mrs L. L. Kingston and Èhe Medical School Workshop staff for expert technical assistance, the colleagues and students who volunteered as subjects for experiments, and Lesley, my wife, for her tireless support. I a¡r indebted to the "X" Bequest, National Health and Medical Research Council, National Heart Foundation of Australia and the University of Adelaide for supPort during the years I968-7L. CONTENTS PREFACE HISTORTCAL REVIEW (A) tutimaL SÈudies (B) Human Studies GENERAL I'IETHOÀS Venous Occlusion
    [Show full text]
  • Supporting Men's Health in the Pharmacy
    SUPPORTING MEN’S HEALTH IN THE PHARMACY Important information about VIAGRA CONNECT® Sildenafil Essential information Sildenafil FULL ESSENTIAL INFORMATION Name of product: VIAGRA CONNECT 50 mg film-coated tabletsActive ingredient(s): sildenafil Product licence number: PL 50622/0063 Name and address of the product licence holder: Upjohn UK Limited, Ramsgate Road, Sandwich, Kent, CT13 9NJ, UK Supply classification: P Indications: For erectile dysfunction in adult men. Side Effects: The safety profile of VIAGRA is based on > 9,000 patients in > 70 double-blind placebo controlled clinical studies. The most commonly reported adverse reactions in clinical studies among sildenafil treated patients were headache, flushing, dyspepsia, nasal congestion, dizziness, nausea, hot flush, visual disturbance, cyanopsia and vision blurred. Adverse reactions from post marketing surveillance has been gathered covering an estimated period >10 years. Because not all adverse reactions are reported to the Marketing Authorisation Holder and included in the safety database, the frequencies of these reactions cannot be reliably determined. Very Common (≥ 1/10): Headache. Common (≥ 1/100 and <1/10): Dizziness, Visual colour distortions (Chloropsia, Chromatopsia, Cyanopsia, Erythropsia and Xanthopsia), Visual disturbance, Vision blurred, Flushing, Hot flush, Nasal congestion, Nausea, Dyspepsia. Uncommon (≥ 1/1,000 and <1/100): Rhinitis, Hypersensitivity; Somnolence; Hypoaesthesia, Lacrimation disorders (Dry eye, Lacrimal disorder and Lacrimation increased), Eye pain,
    [Show full text]
  • The Psychology of Erection Problems
    Introduction EPs are complex and can affect men at any age. Sildenafil They often have both psychological and physical components. Careful questioning will help to ensure that the advice is tailored to each patient. Giving men the opportunity to discuss any medical THE PSYCHOLOGY concerns and issues may highlight opportunities for signposting to other services to improve their overall health. OF ERECTION Men are often reticent to speak to healthcare professionals about their health. Every consultation for EPs gives an opportunity to discuss lifestyle PROBLEMS changes, medication use, health monitoring, mental wellbeing and general health concerns, and support male patients to improve their overall wellbeing. This training is for pharmacy professionals to support them to advise men affected by erection problems (EPs) and recognise opportunities for Remember that you can record any learning and engaging with men about their general health. how you use this information in your consultations as part of your revalidation. Objectives: l Understand the potential psychological causes of EPs l Appreciate how both younger and older men may be affected by EPs l Understand the wider physical and mental health aspects of EPs REFLECTION: Are you confident to signpost men to other services when having conversations about EPs? Do you know what other services are available in your area to support men’s health? Pharmacist Tom Advising on EPs Depression Having difficulty getting or Depression can affect how sustaining an erection hard men feel about themselves enough for sex (called erectile and others, and sufferers are less likely to seek help.1 dysfunction, or erection EPs may either contribute problems) is common and to, or result from, can be treated in many cases.
    [Show full text]
  • Angina: Contemporary Diagnosis and Management Thomas Joseph Ford ‍ ‍ ,1,2,3 Colin Berry ‍ ‍ 1
    Education in Heart CHRONIC ISCHAEMIC HEART DISEASE Heart: first published as 10.1136/heartjnl-2018-314661 on 12 February 2020. Downloaded from Angina: contemporary diagnosis and management Thomas Joseph Ford ,1,2,3 Colin Berry 1 1BHF Cardiovascular Research INTRODUCTION Learning objectives Centre, University of Glasgow Ischaemic heart disease (IHD) remains the leading College of Medical Veterinary global cause of death and lost life years in adults, and Life Sciences, Glasgow, UK ► Around one half of angina patients have no 2 notably in younger (<55 years) women.1 Angina Department of Cardiology, obstructive coronary disease; many of these Gosford Hospital, Gosford, New pectoris (derived from the Latin verb ‘angere’ to patients have microvascular and/or vasospastic South Wales, Australia strangle) is chest discomfort of cardiac origin. It is a 3 angina. Faculty of Health and Medicine, common clinical manifestation of IHD with an esti- The University of Newcastle, ► Tests of coronary artery function empower mated prevalence of 3%–4% in UK adults. There Newcastle, NSW, Australia clinicians to make a correct diagnosis (rule- in/ are over 250 000 invasive coronary angiograms rule- out), complementing coronary angiography. Correspondence to performed each year with over 20 000 new cases of ► Physician and patient education, lifestyle, Dr Thomas Joseph Ford, BHF angina. The healthcare resource utilisation is appre- medications and revascularisation are key Cardiovascular Research Centre, ciable with over 110 000 inpatient episodes each aspects of management. University of Glasgow College year leading to substantial associated morbidity.2 In of Medical Veterinary and Life Sciences, Glasgow G128QQ, UK; 1809, Allen Burns (Lecturer in Anatomy, Univer- tom.
    [Show full text]
  • Hyperemic Brachial Artery Blood Flow Velocity
    Dedication: To my parents for all Your love, care and support! List of Papers This thesis is based on the following papers, which are referred to in the text by their Roman numerals. I Järhult, S.J., Hall, J., Lind, L. (2008) Hyperemic blood-flow velocities in systole and diastole relate to coronary risk in divergent ways. Clinical Physiology and Functional Imaging 28(3)189-95 II Järhult, S.J., Sundström, J., Lind, L. (2009) Brachial artery hyperemic blood-flow velocities are related to carotid atherosclerosis. Clinical Physiology and Functional Imaging 29(5):360-5. III Järhult, S.J, Sundstrom, J, Lind, L. Brachial artery hyperemic blood flow velocity and left ventricular geometry. Submitted. IV Järhult, S.J, Hansen, T., Ahlström, H., Johansson, L., Sundström, J., Lind, L. Brachial artery hyperemic blood flow velocity in relation to established indices of vascular function and global atherosclerosis. Submitted. Reprints were made with permission from the respective publishers. Contents Introduction...................................................................................................13 The cardiovascular system............................................................................14 Structure, function and main regulation...................................................14 Atherosclerosis..............................................................................................17 Risk factors for cardiovascular disease.........................................................19 Scoring systems........................................................................................20
    [Show full text]
  • Propofol Bradycardia Effect of Propofol Anesthesia on Barorcflex Activity in Hu- Mans
    CORRESPONDENCE 137 extensive block cannot be excluded when such large activity .7 The role of rapid injection of the solvent vehicle volumes of local anaesthetic solution are employed. is also possible, in experimental fat embolism, bradycar- Again, this has not been a problem and we believe that it is dia and even atriso-ventricular block were observed and the probable malplacement of the catheter in the antero- associated with right coronary ischaemia. 8 Severe intra- lateral space and resultant poor block that provides some lipid-induced transient sinus bradycardia has been ob- protection against such extensive blocks. Finally, we served. 9 Furthermore, in a dog model of ischaemia, would caution against the use of this technique in patients induced by partial occlusion of the left inter-ventricular who have experienced accidental dural puncture during coronary artery, IV intralipid decreased regional myo- the placement of the epidural catheter. There is the cardial blood flow in the subendocardial and subepicardial potential for transdural passage of the injected chloro- layers,~~ perhaps because of increased blood viscosity. procaine and decreased neurotoxicity of the new prepara- tions has not yet been affirmed. Marc Freysz, MD PhD D6partement d'Anesth6sie-R6animation Edward Crosby asc MD FRCPC H6pital G6n6ral, CHRU Dijon, Universit6 de Bourgogne Dennis Read MB FFARCSFRCPC 21033 Dijon C6dex France Ottawa General Hospital Quadiri Timour PhD Lucien Bertrix MD PhD REFERENCES Georges Faucon MD PhD I Shnider SM. Levinson G. Anaesthetic for Caesarean Sec- Laboratoire de Pharmacologie M6dicale tion. In: Shnidcr SM, Lcvinson G (Eds.). Anesthesia for Facult6 de M6decine CI. Bernard obstetrics, 2nd Ed.
    [Show full text]
  • Persistent Tachycardia Following Subconjunctival Injections Of
    LETTERS TO THE JOURNAL Sir, mg atropine, 0.12 mg adrenaline and 6 mg procaine Persistent Tachycardia Following Subconjunctival (Mydricaine No. 2, formulated by Moorfields Eye Injections of Mydriatic Agents (Mydricaine) Used Hospital). We report three instances in previously for Maintenance of Peri operative Mydriasis in healthy individuals of prolonged supraventricular Vitreoretinal Surgery tachycardia induced by the subconjunctival injection The adverse effects of mydriatic agents are well of these mydriatic agents. documented. These include severe hypertension, subarachnoid haemorrhage, ventricular arrhyth­ Case Reports mias, and myocardial infarction.1 Subconjunctival All three patients had surgery under general injections of mydriatic agents are recommended by anaesthesia, which was performed by the same some authorities to dilate pupils in uveitic patients senior anaesthetist. The induction agents used for with posterior synechiae? These agents are also used anaesthesia were identical, i.e. fentanyl and propofol. to achieve and maintain mydriasis perioperatively Anaesthesia was maintained in each patient by a during prolonged vitreoretinal procedures. These mixture of 70% nitrous oxide, 29% oxygen and 1 % injections can lead to significant systemic absorption isofiurane. Ventilation was maintained with inter­ and serious complications? the risk being enhanced mittent positive pressure via a laryngeal mask. No by conjunctival hyperaemia. anticholinergic drugs were used by the anaesthetist. Following induction of anaesthesia patients
    [Show full text]
  • CARDIOLOGY (Krok2test) a Patient with Unstable Angi-Na Pectoris Was
    CARDIOLOGY (KROK2test) A patient with unstable angi-na pectoris was given the following complex treatment: anticoagulants, ni-trates, /alpha-adrenoblockers. However on the third day of treatment the pain still romains. Which in vestigation shoud be carried out to establish diagnosis? A.Coronarography B.Stress-echocardiogram C.Test with dosed physical exercises D.Esophageal electrocardiac stimulator E.Myocardial scintigraphy A 52 y.o. man has recurrent transi-ent ischemic attacks. Auscultation of the carotid arteries detects murmur. What diagnostic method is necessary to apply first? A.Ultrasound dopplerography B.CTof the brain C.MRI of the brain D.Cerebral angiography E.Electroencephalography A 67 y.o. patient complains of palpitation, dizziness, noise in ears, feeling of shortage of air. Objectively: pale, damp skin. Vesicular respiration, respiratory rate- 22 per min, pulse- 200 bpm, AP-100/70 mm Hg. On ECG: heart rate-200 bmp, ventricular complexes are widened, deformed, location of segments ST and of wave T is discordant. The wave Р is not changed, superimposes QRST, natural conformity between Р and QRS is not present. What kind of arrhythmia is present? A.Paroxismal ventricular tachycardia B.Sinus tachycardia C.Atrialflutter D.Ventricular extrasystole E.Atrial tachycardia A 40 y.o. patient of rheumatic heart disease complains of anorexia, weakness and loss of weigth, breathless and swelling of feet. On examination:t0-390C, pulse is 100/min. As ucultation: diastolic murmur in the mitral area. Petechical lesion a round clavicle; spleen was palpable, tooth extraction one month ago. A.Subacute bacteria endocarditis B.Recurrence of rheumatic fever C.Thrombocytopenia purpure D.Mitral stenosis E.Aortic stenosis A19 y.o.man was admitted to the reception department in 20 minutes after being wounded with the knife to the left chest.
    [Show full text]
  • Short-Term Accomodation by Increased Heart Rate INCREASE of the HEART RATE and ITS LIMITS
    Short-term accomodation by increased heart rate INCREASE OF THE HEART RATE AND ITS LIMITS A2 Pathological ratio: heart 170 syst:diast = 60:40 rate/min 160 Limits: - decrease of diastolic 150 filling time 140 - A2 starts during the ventricular systole 130 120 110 A1 and A2 : beginning of the atrial systole 100 90 80 70 60 A1 50 Physiological ratio: 40 syst:diast = 40:60 0 20 40 60 80 100 120 140 time in 1/100 sec 2 Ventricular sy stole Ventricular diastole COMPENSATION OF HEART FAILURE IN ORDER TO MAINTAIN SUFFICIENT ARTERIAL BLOOD PRESSURE 1. Heart failure (i.e. ↓ pump function, stroke volume and cardiac output) limited elevation of heart rate overlimited elevation of can compensate heart rate can worsen the ↓ situation restored pump function renal blood pressure decreases ↓ ↑ renin ↓ 3 COMPENSATION OF HEART FAILURE IN ORDER TO MAINTAIN SUFFICIENT ARTERIAL BLOOD PRESSURE 2. ↑ renin ↓ atrial natriuretic peptide (ANP): angiotensin I, II (III) a tissue hormone vasoconstriction aldosterone ↓ ↓ ↑ ↑ Na + and water retention peripherial resistance ↓ of blood vessels increased blood volume ↓ ↓ ↑ afterload ↑ preload ↑ arterial blood pressure, ↑ stroke volume, cardiac output (pump function restored ) Overcompensation can easily cause fatal consequences 4 HYPERTENSION Important syndrome in humans (hypertension/hypertonia disease) Causes • Vascular: arterial or capillary stenosis, compression (ie. atherosclerosis) • ! Renal : loss of renal parenchyma, increase of fibrous tissue (chronic renal failure, sclerosis, fibrosis) Important in vet. med.! • Endocrine: - increased function of adrenal medulla and cortex (iatrogen effects included) - hyperthyreosis Local consequence on the heart : hypertrophy ↓ cardiac muscle damage 5 HYPOTENSION There is little importance of primary hypotension/hypotonia in veterinary practice.
    [Show full text]