Background-The univariate study of clinical, electrophysiological, or biochemical variables has been shown to predict the outcome in postanoxic coma in about 50% of patients for each type of variable. Previous studies did not, however, consider the prognostic accuracy of a multivariate approach. Methods-Sixty patients in coma for more than six hours after cardiac arrest were prospectively examined by means of repeated clinical examinations (including Glasgow coma score (GCS)), EEG, and medianus nerve somatosensory evoked potentials (SEPs). In 16 patients, the early concentrations of serum neuron specific enolase and ionised calcium were also measured. Results-Within the first year after cardiac arrest, 20% of patients made a good neurological recovery; 80% remained in a vegetative state or died. Clinical examination correctly predicted outcome in 58% of patients, SEP in 59%, and EEG in 41%. The combination of clinical examination, SEP, and EEG raised the percentage of correct predictions to 82%, without false pessimistic predictions. Concentrations of serum neuron specific enolase and ionised calcium were of no additional prognostic help. Multivariate regression analysis identified the association of GCS < 8 at 48 hours with abnormal or absent early cortical SEPs as highly predictive of a bad outcome (risk = 97%, 95% confidence interval = 86-99%). Conclusion-The combination of GCS at 48 hours, SEP, and if these are nonconclusive, EEG, permits a more reliable prediction of outcome in postanoxic coma than clinical examination alone.
Exchangeable sodium, blood volume, plasma norepinephrine (NE), epinephrine, renin and aldosterone levels, and pressor responses to infused NE or angiotensin II (AII) were assessed in ten patients with essential hypertension on placebo, following 6 to 8 weeks of calcium-antagonist nifedipine (NIF), 3 X 10 to 20 mg/day, and after 6 to 8 weeks on NIF combined with the diuretic chlorthalidone (CHLOR), 25 to 50 mg/day. Pressor effects of infused calcium also were evaluated on placebo and NIF. Supine blood pressure was decreased from 151/97 +/- 5/2 (SEM) to 132/88 +/- 6/2 mm Hg after NIF alone (P less than 0.05) and to 124/83 +/- 7/3 mm Hg after NIF + CHLOR (P less than 0.01). Body wt was increased from 72.7 to 73.9 kg on NIF alone (P less than 0.05), but decreased to 72.1 (P less than 0.05 compared with placebo) after adding CHLOR. Exchangeable sodium also rose from 2642 +/- 237 to 3360 +/- 266 mmoles on NIF (+ 27%; P less than 0.01) and returned to control values (2638 +/- 248 mmoles) after addition of CHLOR. Plasma volume was only slightly modified on NIF (from 2621 +/- 193 to 2751 +/- 160 ml; + 5%), but was reduced to 2232 +/- 231 ml on NIF + CHLOR (P less than 0.05). Responses of circulating aldosterone to AII were similarly diminished (P less than 0.01) during both conditions. Heart rate, supine and upright plasma renin, aldosterone and catecholamine levels, and pressor responses to NE, AII, or calcium were not consistently changed.(ABSTRACT TRUNCATED AT 250 WORDS)
Aims To investigate the role of genetic testing in patients with idiopathic atrioventricular conduction disease requiring pacemaker (PM) implantation before the age of 50 years. Methods and results All consecutive PM implantations in Southern Switzerland between 2010 and 2019 were evaluated. Inclusion criteria were: (i) age at the time of PM implantation: < 50 years; (ii) atrioventricular block (AVB) of unknown aetiology. Study population was investigated by ajmaline challenge and echocardiographic assessment over time. Genetic testing was performed using next-generation sequencing panel, containing 174 genes associated to inherited cardiac diseases, and Sanger sequencing confirmation of suspected variants with clinical implication. Of 2510 patients who underwent PM implantation, 15 (0.6%) were young adults (median age: 44 years, male predominance) presenting with advanced AVB of unknown origin. The average incidence of idiopathic AVB computed over the 2010–2019 time window was 0.7 per 100 000 persons per year (95% CI 0.4–1.2). Most of patients (67%) presented with specific genetic findings (pathogenic variant) or variants of uncertain significance (VUS). A pathogenic variant of PKP2 gene was found in one patient (6.7%) with no overt structural cardiac abnormalities. A VUS of TRPM4, MYBPC3, SCN5A, KCNE1, LMNA, GJA5 genes was found in other nine cases (60%). Of these, three unrelated patients (20%) presented the same heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene. Diagnostic re-assessment over time led to a diagnosis of Brugada syndrome and long-QT syndrome in two patients (13%). No cardiac events occurred during a median follow-up of 72 months. Conclusion Idiopathic AVB in adults younger than 50 years is a very rare condition with an incidence of 0.7 per 100 000 persons/year. Systematic investigations, including genetic testing and ajmaline challenge, can lead to the achievement of a specific diagnosis in up to 20% of patients. Heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene was found in an additional 20% of unrelated patients, suggesting possible association of the variant with the disease.
In recent years, a particular emphasis from the European authorities was put on women's health. Different publications emerged in international journals dedicated to this topic. Several studies described the difficulties and the differences in diagnosis and treatment of heart diseases in women emphasising how even common cardiac conditions are often undertreated and misdiagnosed. The Swiss Society of Cardiology annual congress this year was also dedicated to the topic "Women and the Heart", underlying the nationwide relevance of the problem. These data demonstrate the need for more specific attention and research on female aspects of cardiovascular care. Besides the typical manifestations of heart disease, such as acute coronary syndromes, angina or hypertension which have a similar prevalence in both genders, there is a syndrome mostly affecting perimenopausal women. It is defined as Cardiac syndrome X (CSX), and is a clinical condition usually characterised by anginal pain, positive exercise stress testing and negative coronary angiography. Although t he prognosis according to previous studies was thought to be good, it is now appreciated that these women face significantly greater morbidity than once believed, with an uncertain treatment course and a substantial cost burden to the health care system. Thus, this particular syndrome deserves special attention from health care professionals. Different pathophysiological mechanisms have been proposed to explain the nature of this syndrome. In this article we will review the literature data on CSX with a special focus on symptoms, pathophysiologic mechanisms, difficulties in management and prognosis in this particular group of patients, sharing the authors' experience in this field as well.
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