Background In cases of evolving myocardial injury not definitively attributed to coronary ischaemia precipitated by plaque rupture, referral for invasive coronary angiography (ICA) may be influenced by observed troponin profiles. We sought to explore association between early ICA and elevated high-sensitivity troponin T (hs-cTnT) concentrations with and without dynamic changes, to examine if there may be a hs-cTnT threshold associated with benefit from an initial ICA strategy. Methods Using published studies (hs-cTnT study n = 1937, RAPID-TnT study n = 3270) and the Fourth Universal Definition of Myocardial Infarction (MI), index presentations of patients with hs-cTnT concentrations 5-14ng/L were classified as ‘non-elevated’ (NE). Hs-cTnT greater than upper reference limit (14ng/L) were classified as ‘elevated hs-cTnT with dynamic change’ (encompassing acute myocardial injury, Type 1 MI, and Type 2 MI), or ‘non-dynamic hs-cTnT elevation’ (chronic myocardial injury). Patients with hs-cTnT <5ng/L and/or eGFR<15mmol/L/1.73m2 were excluded. ICA was performed within 30 days of admission. Primary outcome was defined as composite endpoint of death, MI, or unstable angina at 12 months. Results Altogether, 3620 patients comprising 837 (23.1%) with non-dynamic hs-cTnT elevations and 332 (9.2%) with dynamic hs-cTnT elevations were included. Primary outcome was significantly higher with dynamic and non-dynamic hs-cTnT elevations (Dynamic: HR: 4.13 95%CI:2.92–5.82; p<0.001 Non-dynamic: HR: 2.39 95% confidence interval [CI]:1.74–3.28, p<0.001). Hs-cTnT thresholds where benefit from initial ICA strategy appeared to emerge was observed at 110ng/L and 50ng/L in dynamic and non-dynamic elevations, respectively. Conclusion Early ICA appears to portend benefit in hs-cTnT elevations with and without dynamic changes, and at lower hs-cTnT threshold in non-dynamic hs-cTnT elevation. Differences compel further investigation.
Passive leg raise (PLR) during cardiopulmonary resuscitation (CPR) is simple and noninvasive maneuver, which can potentially improve patientrelated outcomes. Initial CPR guidelines have previously advocated "elevation of the lower extremities to augment artificial circulation during CPR. " There is lack of supporting evidence for this recommendation. DESIGN:This was a double cross-over physiologic efficacy randomized study. SETTING AND PATIENTS:Study in 10 subjects with in-hospital cardiac arrest for whom CPR was undertaken.INTERVENTION: Subjects were randomized to receive two cycles of CPR with PLR followed by two cycles of CPR without PLR (Group I) or vice-versa (Group II). Subjects had their foreheads (right and left) fitted with near infrared spectroscopy (NIRS) electrodes (O3 System-Masimo, Masimo corporation Forty Parker, Irvine CA) while undergoing CPR during the study. NIRS readings, a measure of mixed venous, arterial, and capillary blood oxygen saturation, act as a surrogate measure of cerebral blood perfusion during CPR. MEASUREMENT AND MAIN RESULTS:PLR was randomly used "first" in five of them, whereas it was used "second" in the remaining five subjects. In subjects in whom PLR was performed during first two cycles (Group I), NIRS values were initially significantly greater. The performance of PLR during CPR in Group II attenuated the decline in NIRS readings during CPR. CONCLUSIONS: PLR during CPR is feasible and leads to augmentation of cerebral blood flow. Furthermore, the expected decline in cerebral blood flow over time during CPR may be attenuated by this maneuver. The clinical significance of these findings will require further investigations.
Background Cardiac tamponade is the most feared manifestation of purulent bacterial pericarditis (PBP), a rare form of pericarditis in immunocompetent adults. PBP remains a diagnostic challenge given its atypical associated clinical and investigative features. Consequently, PBP carries exceedingly high mortality rates due to fulminant sepsis, and morbidity including constrictive pericarditis in survivors. We present our management of a patient presenting with cardiac tamponade, who subsequently developed constrictive pericarditis due to Actinomyces meyeri PBP. Source control and symptom relief was achieved only with combined intravenous antibiotics, surgical evacuation and pericardiectomy. Case summary A 53-year-old Caucasian male presented with acute New York Heart Association Class IV symptoms, on an 8-week history of recurrent pericarditis presumed secondary to recent viral infection. Initial transthoracic echocardiography (TTE) demonstrated a large asymmetric pericardial effusion for which he underwent urgent pericardiocentesis. Unexpectedly, repeat TTE demonstrated effusion re-accumulation and effusive-constrictive pericarditis, confirmed on cardiac magnetic resonance imaging. Fluid culture was positive for Actinomyces meyeteri. He was diagnosed with primary PBP and deteriorated despite appropriate intravenous antibiotic therapy, necessitating semi-urgent surgical pericardiectomy. He recovered well and was discharged home day 10 postoperatively. Discussion Unlike uncomplicated acute viral or idiopathic pericarditis, PBP portends a very poor prognosis if unrecognised and untreated. Diagnostic challenges persist given its rarity in modern clinical practice, however PBP should be considered in cases of seemingly recurrent pericarditis. Multi-modal cardiac imaging and careful analysis of pericardial fluid including cultures and lactate dehydrogenase/serum ratios may assist in earlier recognition.
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