Aims: The ability to differentiate high risk and low risk patients in ICCU is beneficial. Hemodynamic profiles can be used to describe patient’s condition immediately. Based on the presence of congestion and poor perfusion, patients can be divided into four hemodynamic profiles. We aim to evaluate the prognostic value of hemodynamic profiles for patient’s mortality and length of stay (LOS) in intensive cardiac care unit (ICCU). Methods: In this retrospective cohort study, patients who admitted to ICCU of National Cardiovascular Center Harapan Kita Jakarta, Indonesia, were classified into four hemodynamic profiles: dry-warm, dry-cold, wet-warm, and wet-cold. Bivariate analysis was performed to see the significance between hemodinamic profiles with mortality and LOS, continued with multvariate analysis to evaluate the contribution of other significant factors. Results: Of 742 patients included, the mortality rate was 7.8%. With dry-warm profile as reference, relative risk for mortality was 2.3 (95% CI 1.303-4.076), 5.8 (95% CI 1.992-16.906), and 8.7 (95% CI 3.513-21.567) for wet-warm, dry-cold and wet cold, consecutively. Mean differences of LOS (days) as follows: wet-warm (1.719; 95% CI 1.21-2.23), dry-cold (3.418; 95% CI 1.52-5.32), and wet-cold (4.654; 95% CI 2.64-6.67) compared to dry-warm. Hemodynamic profiles, especially wet-cold profile, consistently predicted mortality and longer LOS in ICCU by multivariable analysis. Conclusion: The presence of “wet” profile double the risk of death, “cold” profile has five fold risk of death, while the presence of both has the highest risk for mortality and longer LOS. Hemodynamic profiles assessme Abstrak Latar Belakang: Kemampuan untuk membedakan pasien resiko tinggi dan resiko rendah di ICCU sangat penting. Profil hemodinamik dapat digunakan untuk mengenali kondisi pasien secara cepat. Berdasarkan adanya tanda kongesti dan perfusi yang buruk pasien dapat dikelompokkan ke dalam empat profil hemodinamik. Studi ini bertujuan untuk mengevaluasi nilai prognostik profil hemodinamik terhadap mortalitas dan lama rawat pasien di Intensive Cardiac Care Unit (ICCU). Metode : Studi kohort retrospektif ini dilakukan di Rumah Sakit Pusat Jantung dan Pembuluh Darah Nasional Harapan Kita, Jakarta, Indonesia. Pasien yang dirawat di ICCU dikelompokkan ke dalam empat profil hemodinamik: kering-hangat, kering-dingin, basah-hangat dan basah-dingin. Analisis bivariate dilakukan untuk menilai hubungan antara profil hemodinamik dengan mortalitas dan lama rawat di ICCU, dilanjutkan dengan analisis multivariate untuk mengevaluasi kontribusi faktor-faktor lain yang signifikan Hasil : Total pasien yang ikut dalam studi sebanyak 742 pasien dan tingkat mortalitas sebesar 7,8%. Resiko relatif (RR) mortalitas untuk profil basah-hangat, kering-dingin dan basah-dingin berturut-turut sebesar 2.3 (95% CI 1.303-4.076), 5.8 (95% CI 1.992-16.906), dan 8.7 (95% CI 3.513-21.567) bila dibandingkan terhadap profil kering-hangat sebagai referensi. Rerata perbedaan lama rawat sebesar 1.719 (95% CI 1.21-2.23), 3.418 ( 95% CI 1.52-5.32), (4.654 (95% CI 2.64-6.67) untuk profil basah-hangat, kering-dingin, dan basah dingin berturut-turut bila dibandingkan dengan profil kering-hangat. Profil hemodinamik, terutama profil basah-dingin secara konsisten memprediksi mortalitas dan lama rawat yang lebih panjang setelah analisis multivariat. Kesimpulan: Profil “basah” memiliki resiko mortalitas dua kali lipat, profil “dingin” memiliki resiko mortalitas lima kali lipat, sedangkan keduanya secara bersamaan memiliki resiko mortalitas dan lama rawat lebih panjang paling tinggi. Profil hemodinamik dapat digunakan sebagai prediktor mortalitas dan lama rawat pasien di ICCU secara efektif.
Objective: External counterpulsation (ECP) provides long-term benefits of improved anginal frequency and exercise tolerance in patients with refractory angina (RA). This is postulated as a result of improved angiogenesis and endothelial function through an increase in shear stress. Angiogenesis is mainly represented by vascular endothelial growth factor-A (VEGF-A) and its receptor, vascular endothelial growth factor receptor-2 (VEGFR-2). The microRNA-92a (miR-92a) is a flow-sensitive miRNA that regulates atherosclerosis and angiogenesis in response to shear stress. Thus, ECP beneficial effect might be achieved through interaction between VEGF-A, VEGFR-2, and miR-92a. This study aims to evaluate the ECP effect on VEGF-A, VEGFR-2, and miR-92a in patients with RA in a sham-controlled manner.Methods: This was a randomized sham-controlled trial, enrolling 50 patients with RA who have coronary artery disease (CAD). Participants were randomized (1:1 ratio) to 35 sessions of either ECP (n = 25) or sham (n = 25), each session lasting for 1 h. Plasma levels of VEGF-A and VEGFR-2 were assayed by the ELISA technique. The quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was performed to measure miR-92a circulating levels in plasma.Result: External counterpulsation significantly preserved VEGF-A and VEGFR-2 level compared to sham [ΔVEGF-A: 1 (−139 to 160) vs.−136 (−237 to 67) pg/ml, p = 0.026; ΔVEGFR-2: −171(-844 to +1,166) vs. −517(−1,549 to +1,407) pg/ml, p = 0.021, respectively]. Circulating miR-92a increased significantly in ECP [5.1 (4.2–6.4) to 5.9 (4.8–6.4), p < 0.001] and sham [5.2 (4.1–9.4) to 5.6 (4.8–6.3), p = 0.008] post-intervention. The fold changes tended to be higher in ECP group, although was not statistically different from sham [fold changes ECP = 4.6 (0.3–36.5) vs. sham 2.8 (0–15), p = 0.33)].Conclusion: External counterpulsation improved angiogenesis by preserving VEGF-A and VEGFR-2 levels. Both ECP and sham increased miR-92a significantly, yet the changes were not different between the two groups. (Study registered on www.clinicaltrials.gov, no: NCT03991871, August 8, 2019, and received a grant from the National Health Research and Development of Ministry of Health of Indonesia, No: HK.02.02/I/27/2020).
A 24-year-old male patient came to the emergency room with melena, gum bleeding and nosebleeds. This patient has a history of mechanical prosthetic mitral valve replacement for severe mitral regurgitation (MR) and consumed warfarin irregularly, but did not come back for regular check-up. Investigations showed greatly increased thyroid function and international normalised ratio (INR) was 15.8. Patients were diagnosed with thyroid storm and bleeding due to prolongation of INR. His hyperthyroid state might have caused increased rate of degradation of vitamin K-dependent clotting factor thereby increased sensitivity to warfarin. Concomitant acute decompensated heart failure, thrombocytopenia and hypoalbuminemia also contributed to his risk of bleeding. Treatment included anti-thyroid therapy as well as warfarin reversal therapy by stopping warfarin, low-dose intravenous vitamin K due to his mechanical prosthetic valve and fresh frozen plasma. In conclusion, hyperthyroidism could increase the response to warfarin so close monitoring is needed to balance the risk of bleeding and thromboembolism.
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