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Cho DH, Thom SR, Son JW, Ko SM, Cha YS. Practical Recommendations for the Evaluation and Management of Cardiac Injury Due to Carbon Monoxide Poisoning. JACC. HEART FAILURE 2024:S2213-1779(24)00051-9. [PMID: 38385937 DOI: 10.1016/j.jchf.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 02/23/2024]
Abstract
Carbon monoxide (CO) is a relatively frequent cause of poisoning evaluated in emergency departments. The risk of neurologic injuries, such as cognitive, psychological, vestibular, and motor deficits, is 25% to 50%. However, the risk of cardiac injuries should also be considered. Among patients with CO poisoning, the mortality in patients with myocardial injury is approximately 3 times greater than that in patients without myocardial injury. In large-scale studies, up to 69.2% of patients with acute CO poisoning exhibiting elevated troponin I levels and no underlying cardiovascular illnesses had late gadolinium enhancement on cardiac magnetic resonance, suggesting covert CO-induced myocardial fibrosis. Myocardial damage can be evaluated using electrocardiography, echocardiography, computed tomography, and cardiac magnetic resonance. This paper offers recommendations for cardiac evaluations based on our collective experience of managing >2,000 cases of acute CO poisoning with supporting information taken from peer-reviewed published reports on CO poisoning.
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Affiliation(s)
- Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Stephen R Thom
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jung-Woo Son
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Sung Min Ko
- Department of Radiology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Yong Sung Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea; Research Institute of Hyperbaric Medicine and Science, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.
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Xu W, Wang W, Xiao Q, Wang Y, Zhu B, Wang P. Effect of Recombinant Human Brain Natriuretic Peptide on Acute Carbon Monoxide Poisoning Complicated with Heart Failure with Reduced Ejection Fraction. Int Heart J 2022; 63:312-318. [PMID: 35354752 DOI: 10.1536/ihj.21-170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This paper aims to observe the effect of recombinant human brain natriuretic peptide (rhBNP) on treatment of acute carbon monoxide poisoning (ACMP) complicated with heart failure with reduced ejection fraction (HFREF).A total of 103 patients with ACMP complicated with HFREF admitted to our department from October 2016 to March 2020 were observed. Patients were divided into control group (50 cases) and experimental group (53 cases). The control group was given diuretic, vasodilator, and digitalis treatment, and the experimental group was supplemented with rhBNP treatment based on the control group. Patients' general information was collected. The levels of myocardial injury-associated indicators of patients were detected at and after admission.No significant differences were observed in the general data of patients compared with control group. The acute physiology and chronic health enquiry II score of patients was positively correlated with left ventricular ejection fraction (LVEF). At admission, the levels of myocardial injury indicators, N-terminal B-type brain natriuretic peptide, and cardiac ultrasound indexes had no significant difference between the control group and experimental group. However, after admission, the LVEF and stroke output levels were elevated, while the other indicators were all decreased compared with the control group.The rhBNP exerts a protective effect on ACMP-induced cardiomyocyte injury to improve cardiac function, shorten the length of hospital stay, and reduce the incidence and mortality of delayed encephalopathy after carbon monoxide poisoning.
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Affiliation(s)
- Wenpin Xu
- Department of Geriatrics, Harrison International Peace Hospital
| | - Weizhan Wang
- Department of Emergency, Harrison International Peace Hospital
| | - Qingmian Xiao
- Department of Emergency, Harrison International Peace Hospital
| | - Yan Wang
- Department of Emergency, Harrison International Peace Hospital
| | - Baoyue Zhu
- Department of Emergency, Harrison International Peace Hospital
| | - Pu Wang
- Department of Emergency, Harrison International Peace Hospital
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Liu Y, Gao X, Xiao Q, Wang W, Zhu B. Correlation Between QTc Dispersion and Soluble Growth-stimulating Gene 2 Protein on the Early Prognosis of Acute Carbon Monoxide Poisoning Heart Disease. J Cardiovasc Pharmacol 2021; 78:572-580. [PMID: 34166304 DOI: 10.1097/fjc.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 06/05/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT This study aimed to explore the correlation between QTc dispersion (QTcd) and soluble growth-stimulating gene 2 protein (sST2) after heart rate correction in patients with acute carbon monoxide poisoning heart disease. Among the 150 patients, 35 cases had severe toxic heart disease. The concentrations of sST2, cardiac troponin I, and creatine kinase-MB in the severe group began to increase from admission, 24 hours, and 2 days, respectively, and their detected values were all higher than those in the nonsevere group and the normal control group. There were statistically significant differences in sST2 and QTcd between the poisoning, nonsevere, and normal control groups before the treatment. There was a statistically significant difference between the indexes of the poisoning groups at different degrees 2 and 3 days after poisoning. Receiver operating characteristic curve analysis confirmed the sensitivity and specificity of sST2 and QTcd. The correlation analysis showed that sST2 and QTcd levels were positively correlated with the incidence of severe heart disease at admission. Generally, the combined observation of sST2 and QTcd improved the prediction sensitivity and were early predictor indexes of toxic heart disease.
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Affiliation(s)
- Yongjian Liu
- Department of Emergency, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hebei, China
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Cho DH, Ko SM, Son JW, Park EJ, Cha YS. Myocardial Injury and Fibrosis From Acute Carbon Monoxide Poisoning: A Prospective Observational Study. JACC Cardiovasc Imaging 2021; 14:1758-1770. [PMID: 33865788 DOI: 10.1016/j.jcmg.2021.02.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study sought to evaluate the prevalence and patterns of late gadolinium enhancement (LGE) after carbon monoxide (CO) poisoning using cardiac magnetic resonance (CMR) imaging (CMRI) and transthoracic echocardiography (TTE). BACKGROUND In acute CO poisoning, cardiac injury can predict mortality. However, it remains unclear why increased mortality and cardiovascular events occur despite normalization of CO-induced elevated troponin I (TnI) and cardiac dysfunction. METHODS Patients with acute CO poisoning with elevated TnI were evaluated. CMRI was performed within 7 days of CO exposure and after 4 to 5 months. Patients were divided into LGE (n = 72; 69.2%) and no-LGE (n = 32; 30.8%) groups. RESULTS In the LGE group, 39.4%, 4.8%, and 25.0% of patients exhibited midwall, subendocardial, and right ventricular insertion point injury, respectively. Diffuse injury was observed in 22.1% of patients, and 67.6% of the 37 patients who underwent follow-up CMRI showed no interval change. On TTE, baseline left ventricular ejection fraction and global longitudinal strain were significantly deteriorated in the LGE group; serial TTE within 7 days indicated that only left ventricular global longitudinal strain remained significantly deteriorated. Three cases of mortality occurred in the LGE group during the 1-year follow-up. CONCLUSIONS The LGE prevalence in patients with acute CO poisoning with elevated TnI levels, with no underlying cardiovascular diseases and eligible for CMRI, was 69.2%; this proportion primarily comprised patients with a midwall injury. Of the 37 patients who underwent follow-up CMRI, most chronic phase images showed no interval change. Myocardial fibrosis detected on CMR images was related to acute myocardial dysfunction and subacute deterioration of myocardial strain on TTE. (Cardiac Magnetic Resonance Image in Acute Carbon Monoxide Poisoning; NCT04419298).
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Affiliation(s)
- Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Sung Min Ko
- Department of Radiology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jung-Woo Son
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Eung Joo Park
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Yong Sung Cha
- Department of Emergency Medicine and Research Institute of Hyperbaric Medicine and Science, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.
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Liu Q, Gao X, Xiao Q, Zhu B, Liu Y, Han Y, Wang W. A combination of NLR and sST2 is associated with adverse cardiovascular events in patients with myocardial injury induced by moderate to severe acute carbon monoxide poisoning. Clin Cardiol 2021; 44:401-406. [PMID: 33496356 PMCID: PMC7943905 DOI: 10.1002/clc.23550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/05/2021] [Accepted: 01/13/2021] [Indexed: 01/09/2023] Open
Abstract
Background Indicators of adverse cardiovascular events in patients with acute carbon monoxide (CO) poisoning‐induced myocardial injury have not yet been elucidated. Hypothesis This study aimed at determining the risk factors for adverse cardiovascular events in patients with acute CO poisoning‐induced myocardial injury. Methods We enrolled patients with moderate‐to‐severe acute CO poisoning‐induced myocardial injury. Based on the occurrence of adverse cardiovascular events, the patients were assigned into event and non‐event group. Binary logistic regression analysis was performed to analyze the potential risk factors for cardiovascular adverse events. Results A total of 413 eligible patients were enrolled. Among them, 61 (14.8%) patients presented adverse cardiovascular events and were assigned to the event group while 352 patients were assigned to the non‐event group. Univariate analysis revealed that cTnI, Lac, and NLR levels at admission and sST2 at day 3 in the event group were significantly higher compared to those in the non‐event group. Subsequent multivariate analysis revealed that sST2 at day 3 and NLR at admission were independent risk factors for adverse cardiovascular events in patients with acute CO poisoning‐induced myocardial injury. Finally, the sensitivity, specificity, and AUC of sST2 at day 3 combined with NLR for event prediction were 79.5%, 82.8%, and 0.858, respectively. Conclusion A combination of sST2 at day 3 and NLR is a potential predictor for the occurrence of adverse cardiovascular events in patients with acute CO poisoning‐induced myocardial injury. Therefore, cardiovascular risk stratification should be taken into consideration, especially in patients with acute CO poisoning‐induced myocardial injury.
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Affiliation(s)
- Qian Liu
- Department of EICU, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
| | - Xun Gao
- Department of EICU, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
| | - Qingmian Xiao
- Department of Emergency General Ward, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
| | - Baoyue Zhu
- Department of EICU, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
| | - Yongjian Liu
- Department of Emergency Medicine, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
| | - Yongyan Han
- Department of Emergency General Ward, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
| | - Weizhan Wang
- Department of Emergency Medicine, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
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Li N, Gao X, Wang W, Wang P, Zhu B. Protective effects of recombinant human brain natriuretic peptide on the myocardial injury induced by acute carbon monoxide poisoning. Cardiovasc Diagn Ther 2021; 10:1785-1794. [PMID: 33381423 DOI: 10.21037/cdt-20-591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To investigate the protective effect of recombinant human brain natriuretic peptide (rhBNP) on myocardial injury after acute carbon monoxide poisoning (ACOP). Methods We retrospectively reviewed medical records of patients with ACOP and high risk of cardiac events admitted to our hospital, and grouped them into rhBNP group and control group according treatments they received. Patients in control group received conventional treatment while those in rhBNP group were treated with rhBNP intravenously for 72 hours on the basis of conventional treatment. Levels of amino-terminal pro-brain natriuretic peptide (NT-proBNP), cardiac troponin I (cTnI), serum creatine kinase MB fraction (CK-MB), aldosterone (ALD), angiotensin II (AT II), and endothelin-1 (ET-1) prior to and after treatment of rhBNP or conventional treatment were collected. Corrected QT dispersion (QTcd) results were calculated based on the electrocardiography data. The left ventricular end diastolic diameter (LVEDD), interventricular septal thickness (IVS), left ventricular ejection fraction (LVEF), and stroke output (SV) were measured using color Doppler echocardiography. Major adverse cardiovascular events (MACEs) that occurred within 1 month after treatment were recorded. Results A total of 135 patients in the rhBNP group and 136 patients in the control group were enrolled. Baseline characteristics between the two groups were similar at admission. Levels of cTnI, CK-MB, and ET-1 in the rhBNP group were significantly lower than those in the control group at day 1, 2 and 3 after treatment (P<0.05). Compared with the control group, levels of QTcd, ALD and AT II in the rhBNP group were significantly lower at day 3 after treatment (P<0.05). After 7 days of treatment, the reduction of NT-proBNP in the rhBNP group was significantly greater than that in the control group at each day (P<0.05), and LVEF, SV and LVEDD in the rhBNP group were all greater than those in the control group. After 1 month of treatment, the incidence of MACEs in the rhBNP group was significantly lower than that in the control group. Conclusions For patients with ACOP and high risk of cardiac events, early treatment of rhBNP can protect injured cardiomyocytes, prevent the injury of carbon monoxide on heart, and reduce the incidence of MACE.
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Affiliation(s)
- Na Li
- Department of Emergency, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
| | - Xun Gao
- Department of Emergency, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
| | - Weizhan Wang
- Department of Emergency, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
| | - Pu Wang
- Department of Emergency, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
| | - Baoyue Zhu
- Department of Emergency, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, China
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Park JH, Heo R, Kang H, Oh J, Lim TH, Ko BS. Diagnostic performance and optimal cut-off values of cardiac biomarkers for predicting cardiac injury in carbon monoxide poisoning. Clin Exp Emerg Med 2020; 7:183-189. [PMID: 33028061 PMCID: PMC7550812 DOI: 10.15441/ceem.19.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/11/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study aimed to compare the diagnostic performance of cardiac biomarkers and to evaluate the optimal cut-off values for echocardiographic cardiac injury prediction in patients with carbon monoxide (CO) poisoning. METHODS This retrospective observational cohort study included adult patients with acute CO poisoning. Patients who did not undergo transthoracic echocardiography, which was used to define patients with cardiac injury (ejection fraction <55%), were excluded. The area under the curve was used to evaluate diagnostic performance for cardiac injury prediction. Mann-Whitney U, chi-square, and Fisher exact tests were used to analyze data. RESULTS After excluding the 27 patients who did not undergo echocardiography, 114 patients were included in the study. Fifteen (13.2%) patients had cardiac injury. The area under the curve values for the B-type natriuretic peptide, creatine kinase-myocardial band, and troponin I were 0.711 (95% confidence interval [CI], 0.527-0.895; P=0.011), 0.766 (95% CI, 0.607-0.926; P=0.001), and 0.801 (95% CI, 0.647-0.955; P<0.001), respectively, with optimal cut-off values of 330 pg/mL, 10.1 ng/mL, and 0.455 ng/mL, respectively. The sensitivity, specificity, and positive and negative predictive values of troponin I were 67%, 91%, 53%, and 95%, respectively. CONCLUSION Troponin I showed the best diagnostic performance for predicting cardiac injury in patients with CO poisoning. A cut-off value of 0.455 ng/mL appeared optimal for cardiac injury prediction. However, further studies on cardiac biomarkers and other diagnostic tools in CO poisoning are needed given the low sensitivity of troponin I.
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Affiliation(s)
- Jun Hwan Park
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Ran Heo
- Division of Cardiology, Department of Internal Medicine, Hanyang University Medical Center, Seoul, Korea
| | - Hyunggoo Kang
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jaehoon Oh
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Byuk Sung Ko
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
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Affiliation(s)
- Philippe Hantson
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, Brussels, Belgium
- Louvain Centre for Toxicology and Applied Pharmacology, Cliniques St-Luc, Université catholique de Louvain, Brussels, Belgium
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