No abstract

Hypertensive emergencies (HEs) are frequently accompanied with the release of cardiac troponin I (cTnI); however, determinants and clinical significance of cTnI elevation are largely unknown. A retrospective analysis was performed on patients (n=567) with a diagnosis of HE admitted to two tertiary care centers that primarily serve an inner-city population. Data on demographics, clinical variables, and cTnI were collected through chart review. Using regression analyses, predictors of cTnI elevation were studied and the impact of cTnI on all-cause mortality (data obtained through the Social Security Death Index) was determined. cTnI elevation was observed in 186 (32.3%) admissions with a mean peak cTnI level of 4.06AE14.6 ng ⁄ mL. Predictors of cTnI were age, history of hypercholesterolemia, blood urea nitrogen level, pulmonary edema, and requirement for mechanical ventilation. During a mean follow-up period of 3.1 years, there were 211 deaths (37%). Neither the presence nor the extent of cTnI elevation was associated with mortality, while age, history of coronary artery disease, and blood urea nitrogen level were predictive of mortality. cTnI elevation commonly occurs in the setting of HEs. Despite a high incidence of adverse clinical outcomes, cTnI elevation was not an independent predictor of mortality in this population. J Clin Hypertens (Greenwich). 2011;13:551-556. Ó2011 Wiley Periodicals, Inc.Approximately 72 million people in the United States are affected by hypertension (HTN).1 Hypertensive emergencies (HEs) are characterized by severe elevations in blood pressure (BP) (>180 ⁄ 120 mm Hg), complicated by new or worsening target organ dysfunction, and require immediate reduction in BP to limit end-organ damage. HEs account for 6% of all patients with clinical emergencies presenting to the emergency department. 2,3Patients with HEs frequently have elevations in cardiac biomarkers such as cardiac troponin I (cTnI), despite the absence of symptoms or electrocardiographic (ECG) changes suggesting myocardial infarction. 4,5 However, the importance of cardiac troponin release in HE is currently uncertain.cTnI is a sensitive and specific marker of myocardial cell injury and is of prognostic value in patients with acute coronary syndromes 6 and a variety of other critical care problems. 5,[7][8][9][10][11][12] The frequency, predictors, and clinical relevance of cTnI elevation in the setting of HEs are currently lacking.This study sought to specifically explore the prevalence, clinical determinants, and prognostic significance of cTnI release in patients presenting with HEs.

Eustachian valve endocarditis caused byA ctinomyces species are anaerobic-to-microaerophilic bacteria that survive as normal flora within the mouth, bronchi, gastrointestinal tract, and female genital tract. These organisms are rarely associated with chronic pyogenic or granulomatous infections in the general population.1 Actinomycotic infections are generally limited to the cervicofacial (50%), pulmonary (15%), and intra-abdominal (20%) areas. Cardiac involvement is relatively rare; most infections occur by contiguous metastasis to the pericardium and very rarely by hematogenous metastasis to the cardiac valves.2 Infection of the eustachian valve (EV) by Actinomyces species is extremely rare, having (to our knowledge) been reported only once before. 3 We report a case of EV endocarditis caused by Actinomyces turicensis in an apparently healthy young woman, possibly transmitted by an intrauterine contraceptive device (IUD). In our accompanying review of the relevant literature, we discuss the predisposing factors, the clinical course, and the treatment of various actinomycotic and EV endocarditis. Case ReportIn September 2011, a 30-year-old woman was admitted with right upper quadrant pain and swelling of one week's duration. Her medical history included no recent dental work, no human immunodeficiency viral infection, and no history of intravenous drug use. She had undergone a cesarean section 2 years before presentation, after which an IUD had been placed. Physical examination at admission revealed a firm mass, slightly painful to the touch, in the right upper quadrant. Laboratory results showed marked leukocytosis. A transvaginal ultrasonogram and a computed tomogram revealed multiple large masses in the ovaries, pelvis, and liver that were suspect for extensive metastatic disease, presumably ovarian in origin. Histopathologic studies of tubo-ovarian (Fig. 1A) and liver (Fig. 1B) biopsy samples failed to reveal any malignant cells. Instead, they showed microabscesses with branching filamentous microorganisms consistent with Actinomyces species. The patient subsequently underwent an exploratory laparotomy, which revealed multiple pockets of pus with extensive inflammatory changes and fibrinous adhesions. Evacuation of pus was performed, along with total abdominal hysterectomy, right salpingo-oophorectomy, appendectomy, and lysis of adhesions. Cultures of fluid from both the abdominal cavity and the IUD grew A. turicensis. Multiple sets of blood cultures performed on the day of Case Reports

Hyponatremia is the most common electrolyte abnormality in hospitalized patients and is associated with increased morbidity and mortality. The recognition of the central role that arginin vasopressin plays in the pathogenesis of hyponatremia and the discovery that its actions are mediated by stimulation of V1A and V2 receptors have led to the development of a new class of drugs, the arginin vasopressin antagonists. Conivaptan is a nonselective V1A and V2 receptors antagonist that was the first of this class to be approved by the FDA for the management of euvolemic and hypervolemic hyponatremia. Its short-term safety and efficacy for the correction of hyponatremia have been established by multiple double-blind, randomized, controlled studies. Blocking the effects of arginin vasopressin on V2 receptors produces aquaresis – the electrolyte-sparing excretion of water – an ideal approach to correct hypervolemic hyponatremia. The nonselectivity of conivaptan offers a theoretical advantage for its use in heart failure that may merit further exploration.