BackgroundWidespread use of angiotensin receptor blocker and neprilysin inhibitor (ARNI) remains low, and many patients are unable to tolerate the medication due to hypotension at the currently recommended starting dose.HypothesisThe aim of this study is to assess if lower than standard doses of ARNI, sacubitril/valsartan (S/V), significantly reduces NT‐proBNP and leads to any change in diuretic dose, serum potassium, or creatinine.MethodsIn a retrospective study of 278 patients who were started on a low dose S/V at a single medical center, 45 patients were selected for the study cohort. Patients were subcategorized to Group 1 (n = 10): very low dose S/V (half a tab of 24/26 mg BID), Group 2 (n = 10): very low dose titrated to low dose S/V, and Group 3 (n = 25): low dose S/V (24/26 mg BID). NT‐proBNP, diuretic dose, serum potassium, and creatinine were compared before and after initiation of S/V.ResultsAmong all groups, there was a significant reduction in NT‐proBNP level (Group 1: p < .01, Group 2: p < .01, and Group 3: p < .001). In addition, there was a significant reduction in diuretic dose across all groups combined (furosemide 53 mg/day vs. 73 mg/day; p = .03), with 17.8% (8/45) patients being able to discontinue their diuretic completely. There was no significant change in potassium or creatinine.ConclusionsLower than standard dose of S/V significantly reduces NT‐proBNP and diuretic requirement without change in potassium or creatinine, which provides hope that patients who cannot tolerate standard doses of S/V due to hypotension may be able to receive the benefits of S/V therapy.
Anterior cervical discectomy and fusion (ACDF) is a commonly performed surgery for the treatment of spondylosis, radiculopathy, myelopathy, and trauma to the cervical spine. Esophageal perforation is a rare yet serious complication following ACDF with an incidence of 0.02 to 1.52%. We describe a case of a 24-year-old man who underwent ACDF and corpectomy following a motor vehicle accident who subsequently developed delayed onset esophageal perforation requiring surgical intervention. We believe that the detailed review of the surgical management of esophageal perforation following cervical spine surgery will provide a deeper understanding for the Intensivist in regards to postoperative airway management in these types of patients. Careful extubation over a soft flexible exchange catheter should take place to help reduce the risk of perforation in the event reintubation is required.
The authors provided an excellent review on dabigatran and the issues encountered in patients with stroke. One challenge with dabigatran is the treatment of acute ischemic stroke for which intravenous tissue-type plasminogen activator administration or endovascular cerebral intervention may be warranted. We recently had a 66-year-old female patient who had been taking 150 mg dabigatran orally twice daily for prevention of stroke in atrial fibrillation. Dabigatran was held 3 days before a cardiac ablation procedure but was resumed immediately after the ablation. Within 1 hour of the procedure, she developed an acute ischemic stroke of the right middle cerebral artery M1 artery on CT angiogram, which resulted in global aphasia and left-sided hemiparesis. The stroke onset was within the timeframe for tissue-type plasminogen activator administration and the activated partial thromboplastin time was 32 seconds (normal range, 22.7-36.1 seconds). The referring physicians felt that the risk of bleeding was too great for intravenous tissue-type plasminogen activator administration. She was started on a heparin drip and emergently transferred to our facility for intra-arterial removal of the clot. When the patient arrived to our institution, Ͼ6 hours had passed since symptom onset and her National Institutes of Health Stroke Scale was 7 for disorientation (1), left-sided arm weakness (measured at 2), left facial weakness (2), sensory loss (1), and left arm ataxia (1). Repeat CT angiogram showed the clot had migrated to the distal right middle cerebral artery M1 and M2 bifurcations and on formal angiogram trickle flow present with some collaterals providing flow to the right middle cerebral artery territory from the ipsilateral anterior cerebral artery and external carotid-superficial temporal branches but no large infarct by cerebral blood flow/cerebral blood volume, time to peak imaging, only a large right middle cerebral artery penumbra. Thrombin time was obtained and elevated at 84 seconds (14.4 -22.2 seconds). The patient had normal renal function and was aggressively hydrated to enhance dabigatran clearance. The clot was mechanically aspirated, and there was robust recanalization of the right middle cerebral artery M1 and M2 branches 9 hours postonset. There were no perioperative bleeding complications. There was a tiny distal cortical M4 infarct seen on noncontrast CT imaging the subsequent day. The patient's National Institutes of Health Stroke Scale on postprocedure Day 1 was only 2 for subjective left sensory loss and trace left facial asymmetry with all other components normal. Dabigatran was discontinued permanently and the patient was switched to warfarin therapy because of the uncertainty of this medication in relation to the embolic event. We feel this event was most likely cardioembolic in nature and not directly related to the medication. However a transesophageal echocardiogram failed to reveal any cardio embolic source. Clinicians are likely to encounter future acute ischemic stroke events in patients ta...
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