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Gan T, Chen J, Wang H, Shang C, Xi S, Fan Z, He B, Zhang M, Zhao L. Impact of sequential (first- to third-generation) EGFR-TKI treatment on corrected QT interval in NSCLC patients. Front Oncol 2024; 14:1330165. [PMID: 38774407 PMCID: PMC11106428 DOI: 10.3389/fonc.2024.1330165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/18/2024] [Indexed: 05/24/2024] Open
Abstract
Objective To evaluate the impact of sequential (first- to third-generation) epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) treatment on top-corrected QT interval (top-QTc) in non-small cell lung cancer (NSCLC) patients. Methods We retrospectively reviewed the medical records of NSCLC patients undergoing sequential EGFR-TKI treatment at Shanghai Chest Hospital between October 2016 and August 2021. The heart rate (HR), top-QT interval, and top-QTc of their ECGs were extracted from the institutional database and analyzed. Logistic regression was performed to identify predictors for top-QTc prolongation. Results Overall, 228 patients were enrolled. Compared with baseline (median, 368 ms, same below), both first-generation (376 ms vs. 368 ms, p < 0.001) and sequential third-generation EGFR-TKIs (376 ms vs. 368 ms, p = 0.002) prolonged top-QT interval to a similar extent (p = 0.635). Top-QTc (438 ms vs. 423 ms, p < 0.001) and HR (81 bpm vs.79 bpm, p = 0.008) increased after first-generation EGFR-TKI treatment. Further top-QTc prolongation (453 ms vs. 438 ms, p < 0.001) and HR increase (88 bpm vs. 81 bpm, p < 0.001) occurred after treatment advanced. Notably, as HR elevated during treatment, top-QT interval paradoxically increased rather than decreased, and the top-QTc increased rather than slightly fluctuated. Moreover, such phenomena were more significant after treatment advanced. After adjusting for confounding factors, pericardial effusion and lower serum potassium levels were independent predictors of additional QTc prolongation during sequential third-generation EGFR-TKI treatment. Conclusion First-generation EGFR-TKI could prolong top-QTc, and sequential third-generation EGFR-TKI induced further prolongation. Top-QT interval paradoxically increased and top-QTc significantly increased as HR elevated, which was more significant after sequential EGFR-TKI treatment. Pericardial effusion and lower serum potassium levels were independent predictors of additional QTc prolongation after sequential EGFR-TKI treatment.
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Affiliation(s)
| | | | | | | | | | | | | | - Min Zhang
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Liang Zhao
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Bernikova O, Durkina A, Gonotkov M, Minnebaeva E, Arteyeva N, Azarov J. Formation of a border ischemic zone depends on plasma potassium concentration. Can J Physiol Pharmacol 2024; 102:331-341. [PMID: 38118123 DOI: 10.1139/cjpp-2023-0304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
Extracellular potassium concentration might modify electrophysiological properties in the border zone of ischemic myocardium. We evaluated the depolarization and repolarization characteristics across the ischemic-normal border under [K+] variation. Sixty-four-lead epicardial mapping was performed in 26 rats ([K+] 2.3-6.4 mM) in a model of acute ischemia/reperfusion. The animals with [K+] < 4.7 mM (low-normal potassium) had an ischemic zone with ST-segment elevation and activation delay, a border zone with ST-segment elevation and no activation delay, and a normal zone without electrophysiological abnormalities. The animals with [K+] >4.7 mM (normal-high potassium) had only the ischemic and normal zones and no transitional area. Activation-repolarization intervals and local conduction velocities were inversely associated with [K+] in linear regression analysis with adjustment for the zone of myocardium. The reperfusion extrasystolic burden (ESB) was greater in the low-normal as compared to normal-high potassium animals. Ventricular tachycardia/fibrillation incidence did not differ between the groups. In patch-clamp experiments, hypoxia shortened action potential duration at 5.4 mM but not at 1.3 mM of [K+]. IK(ATP) current was lower at 1.3 mM than at 5.4 mM of [K+]. We conclude that the border zone formation in low-normal [K+] was associated with attenuation of IK(ATP) response to hypoxia and increased reperfusion ESB.
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Affiliation(s)
- Olesya Bernikova
- Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
- Department of Mathematical Physiology, Institute of Immunology and Physiology, Ural Branch, Russian Academy of Sciences, Ekaterinburg, Russia
| | - Aleksandra Durkina
- Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
| | - Mikhail Gonotkov
- Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
| | - Elena Minnebaeva
- Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
- Institute of Medicine, Pitirim Sorokin Syktyvkar State University, Syktyvkar, Russia
| | - Natalia Arteyeva
- Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
| | - Jan Azarov
- Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
- Department of Mathematical Physiology, Institute of Immunology and Physiology, Ural Branch, Russian Academy of Sciences, Ekaterinburg, Russia
- Institute of Medicine, Pitirim Sorokin Syktyvkar State University, Syktyvkar, Russia
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic
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Song J, Liu Y, Li Y, Huang X, Zhang M, Liu X, Hu X. Comparison of bicarbonate Ringer's solution with lactated Ringer's solution among postoperative outcomes in patients with laparoscopic right hemihepatectomy: a single-centre randomised controlled trial. BMC Anesthesiol 2024; 24:152. [PMID: 38649834 PMCID: PMC11034129 DOI: 10.1186/s12871-024-02529-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 04/07/2024] [Indexed: 04/25/2024] Open
Abstract
The study was aimed to investigate the positive impact of bicarbonate Ringer's solution on postoperative outcomes in patients who underwent laparoscopic right hemihepatectomy. Patients in the two groups were infused with lactated Ringer's solution (LRS, n = 38) and the bicarbonate Ringer's solution (BRS, n = 38) at a rate of 5 ml·kg-1·h-1. The stroke volume was monitored and 200 ml of hydroxyethyl starch with 130/0.4 sodium chloride injection (Hes) of a bolus was given in the first 5-10 min. The main outcome was to test lactic acid (LAC) concentration before and after surgery. The concentrations of LAC in the LRS group were higher than in the BRS group at 2 h after operation began, at the end of the operation and 2 h after the operation. Overall, the parameters including pH, base excess (BE), HCO3-, aspartate transaminase (AST) and alanine transaminase (ALT) were improved. The values of bilirubin in the LRS group were higher and albumin were lower than in the BRS group at post-operation 1st and 2nd day (P<0.05). The time of prothrombin time (PT) and activated partial thromboplastin time (APTT) in the LRS group were longer than that in the BRS group at post-operation 1st and 2nd day (P<0.05). Likewise, the concentrations of Mg2+, Na+ and K+ also varied significantly. The length of hospital was reduced, and the incidence of premature ventricular contractions (P = 0.042) and total complications (P = 0.016) were lower in group BRS. TRIAL REGISTRATION: The study was registered at clinicalTrials.gov with the number ChiCTR2000038077 on 09/09/2020.
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Affiliation(s)
- Jie Song
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei City, Anhui Province, China
| | - Yingying Liu
- Department of Anesthesiology, Children's Hospital of Nanjing Medical University, Nanjing City, Jiangsu Province, China
| | - Yun Li
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei City, Anhui Province, China
| | - Xiaoci Huang
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei City, Anhui Province, China
| | - Muchun Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei City, Anhui Province, China
| | - Xiaofeng Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei City, Anhui Province, China
| | - Xianwen Hu
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China.
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei City, Anhui Province, China.
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Kildegaard H, Brabrand M, Forberg JL, Platonov P, Lassen AT, Ekelund U. Prevalence and prognostic value of electrocardiographic abnormalities in hypokalemia: A multicenter cohort study. J Intern Med 2024; 295:544-556. [PMID: 38098171 DOI: 10.1111/joim.13757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Abstract
BACKGROUND Hypokalemia is common in hospitalized patients and associated with ECG abnormalities. The prevalence and prognostic value of ECG abnormalities in hypokalemic patients are, however, not well established. METHODS The study was a multicentered cohort study, including all ault patients with an ECG and potassium level <4.4 mmol/L recorded at arrival to four emergency departments in Denmark and Sweden. Using computerized measurements from ECGs, we investigated the relationship between potassium levels and heart rate, QRS duration, corrected QT (QTc) interval, ST-segment depressions, T-wave flattening, and T-wave inversion using cubic splines. Within strata of potassium levels, we further estimated the hazard ratio (HR) for 7-day mortality, admission to the intensive care unit (ICU), and diagnosis of ventricular arrhythmia or cardiac arrest, comparing patients with and without specific ECG abnormalities matched 1:2 on propensity scores. RESULTS Among 79,599 included patients, decreasing potassium levels were associated with a concentration-dependent increase in all investigated ECG variables. ECG abnormalities were present in 40% of hypokalemic patients ([K+ ] <3.5 mmol/L), with T-wave flattening, ST-segment depression, and QTc prolongation occurring in 27%, 16%, and 14%. In patients with mild hypokalemia ([K+ ] 3.0-3.4 mmol/L), a heart rate >100 bpm, ST-depressions, and T-wave inversion were associated with increased HRs for 7-day mortality and ICU admission, whereas only a heart rate >100 bpm predicted both mortality and ICU admission among patients with [K+ ] <3.0 mmol/L. HR estimates were, however, similar to those in eukalemic patients. The low number of events with ventricular arrhythmia limited evaluation for this outcome. CONCLUSIONS ECG abnormalities were common in hypokalemic patients, but they are poor prognostic markers for short-term adverse events under the current standard of care.
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Affiliation(s)
- Helene Kildegaard
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jakob Lundager Forberg
- Department of Emergency Medicine, Helsingborg Hospital, Helsingborg, Sweden
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Pyotr Platonov
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ulf Ekelund
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Emergency Medicine at Lund, Skåne University Hospital, Lund, Sweden
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Mlambo VC, Algaze CA, Mak K, Collins RT. Impact of Abnormal Potassium on Arrhythmia Risk During Pediatric Digoxin Therapy. Pediatr Cardiol 2024; 45:901-908. [PMID: 36403164 DOI: 10.1007/s00246-022-03051-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 11/09/2022] [Indexed: 11/21/2022]
Abstract
Digoxin is used in children with heart failure and tachyarrhythmia. Its use in patients with single ventricle anatomy has increased following evidence of improved interstage survival after the Norwood procedure. Digoxin has a narrow therapeutic window and may alter serum potassium balance, inducing arrhythmias. We hypothesized digoxin use in the setting of abnormal serum potassium levels is associated with arrhythmias. We reviewed all patients ≤ 18 years who received digoxin while admitted at our institution from 2014 to 2021. Admissions < 2 nights were excluded. We compared patients with a hemodynamically significant arrhythmia to those without. We performed adjusted mixed-effects logistic regression with arrhythmia as the outcome variable and potassium status as the predictor variable; adjusting for weight, route of digoxin administration, digoxin indication, serum creatinine, and number of interacting drugs prescribed. Abnormal potassium was defined as serum levels < 3.5 mmol/L or > 6.0 mmol/L. There were 268 encounters in 171 patients. Potassium levels were abnormal in 75.5% of patients who experienced an arrhythmia during digoxin administration, compared to 42.6% who did not (p < 0.001). Odds of arrhythmia was 138% higher in patients with abnormal potassium receiving digoxin (AOR = 2.38, 95% CI 1.07-5.29, p = 0.03). Receiving intravenous digoxin was also associated with a 7.35 odds of cardiac arrhythmia (AOR 7.35, p = 0.006, 95% CI 1.79-30.26). Odds of arrhythmia is increased during digoxin administration when pediatric patients have abnormal potassium levels. Vigilant attention to potassium levels is essential to prevent adverse outcomes during digoxin therapy.
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Affiliation(s)
- Vongai Christine Mlambo
- Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Claudia A Algaze
- Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Kwai Mak
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - R Thomas Collins
- Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA.
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
- Division of Pediatric Cardiology, University of Kentucky College of Medicine, Lexington, KY, USA.
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6
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Fargaly H, Schultz RJ, Chung UY, Rossi NF. Hypokalemia-Induced Life-Threatening Arrhythmia in a Patient With Congestive Heart Failure. Cureus 2023; 15:e34971. [PMID: 36938242 PMCID: PMC10019554 DOI: 10.7759/cureus.34971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/16/2023] Open
Abstract
Ventricular tachyarrhythmias are common in patients with heart failure. It is one of the important preventable causes of death in these patient populations. Hypokalemia is prevalent in patients with heart failure due to various reasons. Hypokalemia can trigger ventricular arrhythmias through different mechanisms. In this case report, we present a middle-aged man with congestive heart failure (CHF) and an automated intracardiac defibrillator (AICD) on multiple diuretic medications (unintended) who presented with acute chest pain. He was found to have severe hypokalemia, hyponatremia, and an acute kidney injury. Interrogation of the AICD revealed multiple episodes of ventricular fibrillation. The patient was managed by holding his diuretic medications, cautious volume repletion, and potassium replacement. Fortunately, the patient showed rapid clinical improvement and his plasma potassium level improved. On discharge, we reconciled the patient's medications to avoid the recurrence of hypokalemia from over-diuresis and arranged a close follow-up outpatient visit with his cardiologist.
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Affiliation(s)
- Hithem Fargaly
- Nephrology, Wayne State University Detroit Medical Center, Detroit, USA
| | | | - Un Yong Chung
- Nephrology, Wayne State University School of Medicine, Detroit, USA
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Tse G, Zhou J, Dong X, Hao G, Lee S, Leung KSK, Leung FP, Liu T, Du Y, Cheng SH, Wong WT. Nonlinear analysis of beat-to-beat variability of action potential time series data identifies dynamic re-entrant substrates in a hypokalaemic mouse model of acquired long QT syndrome. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2023. [DOI: 10.1186/s42444-023-00084-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Abstract
Background
Previous studies have quantified repolarization variability using time-domain, frequency-domain and nonlinear analysis in mouse hearts. Here, we investigated the relationship between these parameters and ventricular arrhythmogenicity in a hypokalaemia model of acquired long QT syndrome.
Methods
Left ventricular monophasic action potentials (MAPs) were recorded during right ventricular regular 8 Hz pacing during normokalaemia (5.2 mM [K+]), hypokalaemia modeling LQTS (3 mM [K+]) or hypokalaemia with 0.1 mM heptanol in Langendorff-perfused mouse hearts.
Results
During normokalaemia, mean APD was 33.5 ± 3.7 ms. Standard deviation (SD) of APDs was 0.63 ± 0.33 ms, coefficient of variation was 1.9 ± 1.0% and the root mean square (RMS) of successive differences in APDs was 0.3 ± 0.1 ms. Low- and high-frequency peaks were 0.6 ± 0.5 and 2.3 ± 0.7 Hz, respectively, with percentage powers of 38 ± 22 and 61 ± 23%. Poincaré plots of APDn+1 against APDn revealed ellipsoid morphologies with SD along the line-of-identity (SD2) to SD perpendicular to the line-of-identity (SD1) ratio of 4.6 ± 1.1. Approximate and sample entropy were 0.49 ± 0.12 and 0.64 ± 0.29, respectively. Detrended fluctuation analysis revealed short- and long-term fluctuation slopes of 1.62 ± 0.27 and 0.60 ± 0.18, respectively. Hypokalaemia provoked ventricular tachycardia in six of seven hearts, prolonged APDs (51.2 ± 7.9 ms), decreased SD2/SD1 ratio (3.1 ± 1.0), increased approximate and sample entropy (0.68 ± 0.08 and 1.02 ± 0.33) and decreased short-term fluctuation slope (1.23 ± 0.20) (ANOVA, P < 0.05). Heptanol prevented VT in all hearts studied without further altering the above repolarization parameters observed during hypokalaemia.
Conclusion
Reduced SD2/SD1, increased entropy and decreased short-term fluctuation slope may reflect arrhythmic risk in hypokalaemia. Heptanol exerts anti-arrhythmic effects without affecting repolarization variability.
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Charalambous C, Moon JC, Holly JMP, Chaturvedi N, Hughes AD, Captur G. Declining Levels and Bioavailability of IGF-I in Cardiovascular Aging Associate With QT Prolongation-Results From the 1946 British Birth Cohort. Front Cardiovasc Med 2022; 9:863988. [PMID: 35528832 PMCID: PMC9072634 DOI: 10.3389/fcvm.2022.863988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/21/2022] [Indexed: 11/30/2022] Open
Abstract
Background As people age, circulating levels of insulin-like growth factors (IGFs) and IGF binding protein 3 (IGFBP-3) decline. In rat cardiomyocytes, IGF-I has been shown to regulate sarcolemmal potassium channel activity and late sodium current thus impacting cardiac repolarization and the heart rate-corrected QT (QTc). However, the relationship between IGFs and IGFBP-3 with the QTc interval in humans, is unknown. Objectives To examine the association of IGFs and IGFBP-3 with QTc interval in an older age population-based cohort. Methods Participants were from the 1946 Medical Research Council (MRC) National Survey of Health and Development (NSHD) British birth cohort. Biomarkers from blood samples at age 53 and 60-64 years (y, exposures) included IGF-I/II, IGFBP-3, IGF-I/IGFBP-3 ratio and the change (Δ) in marker levels between the 60-64 and 53y sampled timepoints. QTc (outcome) was recorded from electrocardiograms at the 60-64y timepoint. Generalized linear multivariable models with adjustments for relevant demographic and clinical factors, were used for complete-cases and repeated after multiple imputation. Results One thousand four hundred forty-eight participants were included (48.3% men; QTc mean 414 ms interquartile range 26 ms). Univariate analysis revealed an association between low IGF-I and IGF-I/IGFBP-3 ratio at 60-64y with QTc prolongation [respectively: β -0.30 ms/nmol/L, (95% confidence intervals -0.44, -0.17), p < 0.001; β-28.9 ms/unit (-41.93, -15.50), p < 0.001], but not with IGF-II or IGFBP-3. No association with QTc was found for IGF biomarkers sampled at 53y, however both ΔIGF-I and ΔIGF-I/IGFBP-3 ratio were negatively associated with QTc [β -0.04 ms/nmol/L (-0.08, -0.008), p = 0.019; β -2.44 ms/unit (-4.17, -0.67), p = 0.007] while ΔIGF-II and ΔIGFBP-3 showed no association. In fully adjusted complete case and imputed models (reporting latter) low IGF-I and IGF-I/IGFBP-3 ratio at 60-64y [β -0.21 ms/nmol/L (-0.39, -0.04), p = 0.017; β -20.14 ms/unit (-36.28, -3.99), p = 0.015], steeper decline in ΔIGF-I [β -0.05 ms/nmol/L/10 years (-0.10, -0.002), p = 0.042] and shallower rise in ΔIGF-I/IGFBP-3 ratio over a decade [β -2.16 ms/unit/10 years (-4.23, -0.09), p = 0.041], were all independently associated with QTc prolongation. Independent associations with QTc were also confirmed for other previously known covariates: female sex [β 9.65 ms (6.65, 12.65), p < 0.001], increased left ventricular mass [β 0.04 ms/g (0.02, 0.06), p < 0.001] and blood potassium levels [β -5.70 ms/mmol/L (-10.23, -1.18) p = 0.014]. Conclusion Over a decade, in an older age population-based cohort, declining levels and bioavailability of IGF-I associate with prolongation of the QTc interval. As QTc prolongation associates with increased risk for sudden death even in apparently healthy people, further research into the antiarrhythmic effects of IGF-I on cardiomyocytes is warranted.
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Affiliation(s)
- Christos Charalambous
- UCL MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
| | - James C. Moon
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
- Cardiac MRI Unit, Barts Heart Centre, London, United Kingdom
| | - Jeff M. P. Holly
- National Institute for Health Research (NIHR) Bristol Nutrition Biomedical Research Unit, Level 3, University Hospitals Bristol Education and Research Centre, Bristol, United Kingdom
- Faculty of Health Sciences, School of Translational Health Sciences, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, United Kingdom
| | - Nishi Chaturvedi
- UCL MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
| | - Alun D. Hughes
- UCL MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Gabriella Captur
- UCL MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
- Cardiology Department, Centre for Inherited Heart Muscle Conditions, The Royal Free Hospital, London, United Kingdom
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Makinouchi R, Machida S, Matsui K, Shibagaki Y, Imai N. Severe hypokalemia in the emergency department: A retrospective, single‐center study. Health Sci Rep 2022; 5:e594. [PMID: 35509383 PMCID: PMC9059213 DOI: 10.1002/hsr2.594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background and Aims Hypokalemia is one of the most common problems in the emergency department (ED). Severe hypokalemia, defined as a serum potassium level ≤2.5 mEq/L, is a relatively uncommon electrolyte disorder, and few studies have reported its prevalence, etiology, symptoms, and management in the ED. Therefore, we aimed to investigate them in this study. Methods This retrospective single‐center study included adult patients whose serum potassium levels were measured in the ED between 2012 and 2019. Data including age, sex, serum potassium levels, and serum creatinine levels were collected from the electronic medical records. Results The serum potassium levels of 21,616 adult patients were measured. The median age of these patients was 73 years (range: 57–83 years), and 38% were men. The prevalence of severe hypokalemia was 0.4%. The most common symptom of symptomatic severe hypokalemia was weakness (p = 0.001). Malnutrition, use of Japanese herbal medicine, and use of diuretics were the main causes of severe hypokalemia. Sixty‐one patients (70%) underwent electrocardiography. Fifty‐nine patients (68%) received treatment for severe hypokalemia within one day of the visit. Conclusion The management of severe hypokalemia in the ED may be suboptimal. Emergency physicians should be vigilant to avoid missing hypokalemia.
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Affiliation(s)
- Ryuichirou Makinouchi
- Division of Nephrology and Hypertension, St. Marianna University School of Medicine Yokohama City Seibu Hospital Yokohama Kanagawa Japan
| | - Shinji Machida
- Division of Nephrology and Hypertension, St. Marianna University School of Medicine Yokohama City Seibu Hospital Yokohama Kanagawa Japan
| | - Katsuomi Matsui
- Division of Nephrology and Hypertension, St. Marianna University School of Medicine Yokohama City Seibu Hospital Yokohama Kanagawa Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension St. Marianna University School of Medicine Kawasaki Kanagawa Japan
| | - Naohiko Imai
- Division of Nephrology and Hypertension, St. Marianna University School of Medicine Yokohama City Seibu Hospital Yokohama Kanagawa Japan
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10
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Lee DH, Money DB, Deshpande A, Samuels B. A Case of Abiraterone-Related Hypokalemia Leading to Torsades de Pointes and Cardiac Arrest. Cureus 2022; 14:e23678. [PMID: 35505742 PMCID: PMC9055788 DOI: 10.7759/cureus.23678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 03/31/2022] [Indexed: 11/25/2022] Open
Abstract
Abiraterone acetate is an androgen-depriving therapy (ADT) that is highly effective for treating castration-resistant prostate cancer (CRPC). By inhibiting CYP17, abiraterone can induce a state of mineralocorticoid excess, which is associated with profound hypokalemia. We present a case of abiraterone-related hypokalemia which led to torsades de pointes (TdP) and ventricular fibrillation (VF). We reviewed the literature and showed the need for close monitoring of the potassium level and electrocardiogram (ECG) to prevent fatal arrhythmias.
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11
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Hypokalemic Cardiac Arrest: Narrative Review of Case Reports and Current State of Science. J Emerg Nurs 2022; 48:310-316. [PMID: 35144826 DOI: 10.1016/j.jen.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/23/2021] [Accepted: 12/26/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE Hypokalemic cardiac arrest is an uncommon occurrence in the emergency department. Electrocardiogram findings related to hypokalemic cardiac arrest include prolonged QT, U waves, and preventricular contractions leading to Torsades de Pointes and then arrest. Literature evaluating the prevalence of hypokalemic cardiac arrest is scarce, and its management is lacking. This review provides a summary of current literature, recommendations from current guidelines, and proposed management strategies of hypokalemic cardiac arrest. SUMMARY Intravenous potassium administration is the treatment for hypokalemic cardiac arrest. Although the treatment for hypokalemic cardiac arrest is known, there is limited evidence on the proper procedure for administering intravenous potassium appropriately and safely. Owing to the time-sensitive nature of treating hypokalemic cardiac arrest, rapid administration of intravenous potassium (10 mEq/100 mL of potassium chloride over 5 minutes) is warranted. Concerns regarding rapid potassium administration are not without merit; however, a risk-benefit analysis and potential mitigation strategies for unwanted side effects need to be considered if hypokalemic cardiac arrest is to remain a reversible cause. It is imperative to identify hypokalemia as the cause for arrest as soon as possible and administer potassium before systemic acidosis, ischemia, and irreversible cell death. CONCLUSIONS More evidence is necessary to support treatment recommendations for hypokalemic cardiac arrest; however, it is the authors' opinion that, if identified early during cardiac arrest, intravenous potassium should be administered to treat a reversible cause for cardiac arrest.
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12
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Gurung B, Tse G, Keung W, Li RA, Wong WT. Arrhythmic Risk Assessment of Hypokalaemia Using Human Pluripotent Stem Cell-Derived Cardiac Anisotropic Sheets. Front Cell Dev Biol 2021; 9:681665. [PMID: 34938727 PMCID: PMC8685904 DOI: 10.3389/fcell.2021.681665] [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: 03/17/2021] [Accepted: 11/01/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction: Hypokalaemia, defined as an extracellular concentration of K+ below 3.5 mM, can cause cardiac arrhythmias by triggered or re-entrant mechanisms. Whilst these effects have been reported in animal and human stem cell-based models, to date there has been no investigation in more complex structures such as the human ventricular cardiac anisotropic sheet (hvCAS). Here, we investigated arrhythmogenicity, electrophysiological, and calcium transient (CaT) changes induced by hypokalaemia using this bioengineered platform. Methods: An optical mapping technique was applied on hvCAS derived from human pluripotent stem cells to visualize electrophysiological and CaT changes under normokalaemic (5 mM KCl) and hypokalaemic (3 mM KCl) conditions. Results: Hypokalaemia significantly increased the proportion of preparations showing spontaneous arrhythmias from 0/14 to 7/14 (Fisher’s exact test, p = 0.003). Hypokalaemia reduced longitudinal conduction velocity (CV) from 7.81 to 7.18 cm⋅s−1 (n = 9, 7; p = 0.036), transverse CV from 5.72 to 4.69 cm⋅s−1 (n = 12, 11; p = 0.030), prolonged action potential at 90% repolarization (APD90) from 83.46 to 97.45 ms (n = 13, 15; p < 0.001), increased action potential amplitude from 0.888 to 1.195 ΔF (n = 12, 14; p < 0.001) and CaT amplitude from 0.76 to 1.37 ΔF (n = 12, 13; p < 0.001), and shortened effective refractory periods from 242 to 165 ms (n = 12, 13; p < 0.001). Conclusion: Hypokalaemia exerts pro-arrhythmic effects on hvCAS, which are associated with alterations in CV, repolarization, refractoriness, and calcium handling. These preparations provide a useful platform for investigating electrophysiological substrates and for conducting arrhythmia screening.
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Affiliation(s)
- Bimal Gurung
- School of Life Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Gary Tse
- Cardiac Electrophysiology Unit, Cardiovascular Analytics Group, China-UK Collaboration, Hong Kong SAR, China.,Kent and Medway Medical School, Canterbury, Kent, United Kingdom.,Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Wendy Keung
- Novoheart, Irvine, CA, United States.,Dr. Li Dak-Sum Research Centre, HKU-Karolinska Institutet Collaboration in Regenerative Medicine, The University of Hong Kong, Hong Kong SAR, China
| | | | - Wing Tak Wong
- School of Life Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China.,Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China.,State Key Laboratory of Agrobiotechnology, The Chinese University of Hong Kong, Hong Kong SAR, China
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13
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Angelini M, Pezhouman A, Savalli N, Chang MG, Steccanella F, Scranton K, Calmettes G, Ottolia M, Pantazis A, Karagueuzian HS, Weiss JN, Olcese R. Suppression of ventricular arrhythmias by targeting late L-type Ca2+ current. J Gen Physiol 2021; 153:212725. [PMID: 34698805 PMCID: PMC8552156 DOI: 10.1085/jgp.202012584] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/15/2021] [Accepted: 09/02/2021] [Indexed: 12/15/2022] Open
Abstract
Ventricular arrhythmias, a leading cause of sudden cardiac death, can be triggered by cardiomyocyte early afterdepolarizations (EADs). EADs can result from an abnormal late activation of L-type Ca2+ channels (LTCCs). Current LTCC blockers (class IV antiarrhythmics), while effective at suppressing EADs, block both early and late components of ICa,L, compromising inotropy. However, computational studies have recently demonstrated that selective reduction of late ICa,L (Ca2+ influx during late phases of the action potential) is sufficient to potently suppress EADs, suggesting that effective antiarrhythmic action can be achieved without blocking the early peak ICa,L, which is essential for proper excitation–contraction coupling. We tested this new strategy using a purine analogue, roscovitine, which reduces late ICa,L with minimal effect on peak current. Scaling our investigation from a human CaV1.2 channel clone to rabbit ventricular myocytes and rat and rabbit perfused hearts, we demonstrate that (1) roscovitine selectively reduces ICa,L noninactivating component in a human CaV1.2 channel clone and in ventricular myocytes native current, (2) the pharmacological reduction of late ICa,L suppresses EADs and EATs (early after Ca2+ transients) induced by oxidative stress and hypokalemia in isolated myocytes, largely preserving cell shortening and normal Ca2+ transient, and (3) late ICa,L reduction prevents/suppresses ventricular tachycardia/fibrillation in ex vivo rabbit and rat hearts subjected to hypokalemia and/or oxidative stress. These results support the value of an antiarrhythmic strategy based on the selective reduction of late ICa,L to suppress EAD-mediated arrhythmias. Antiarrhythmic therapies based on this idea would modify the gating properties of CaV1.2 channels rather than blocking their pore, largely preserving contractility.
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Affiliation(s)
- Marina Angelini
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Arash Pezhouman
- Department of Medicine (Cardiology), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Nicoletta Savalli
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Marvin G Chang
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Federica Steccanella
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Kyle Scranton
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Guillaume Calmettes
- Department of Medicine (Cardiology), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Michela Ottolia
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,University of California, Los Angeles Cardiovascular Theme, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Antonios Pantazis
- Division of Neurobiology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Wallenberg Center for Molecular Medicine, Linköping University, Linköping, Sweden
| | - Hrayr S Karagueuzian
- Department of Medicine (Cardiology), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,Cardiovascular Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - James N Weiss
- Department of Medicine (Cardiology), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,Cardiovascular Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Riccardo Olcese
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,Cardiovascular Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,University of California, Los Angeles Cardiovascular Theme, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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14
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Ren Y, Wang Y, Yan H, Chen L, Mao Q. Cardiovascular crisis after use of epinephrine: a case report and review of the literature. AME Case Rep 2021; 5:31. [PMID: 34805750 DOI: 10.21037/acr-20-161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 04/22/2021] [Indexed: 11/06/2022]
Abstract
Diluted epinephrine is often locally used to provide hemostasis and improve visualization. However, rapid absorption or inadvertent intravascular injection of epinephrine can cause unexpected cardiovascular effects. A 28-year-old man was scheduled to undergo a nasal septoplasty. After local application of 0.01% epinephrine-soaked nasal pledgets and infiltration of 3 mL 0.001% epinephrine, the patient developed a severe hypertension of 205/126 mmHg, followed by ventricular tachycardia. Cardiac arrest ensued after intravenous injection of lidocaine and esmolol in an attempt to control ventricular arrhythmia. After successful resuscitation, the patient was transferred to the intensive care unit (ICU) and fully recovered in 5 days. While another two epinephrine-induced hypertension cases were treated smoothly without β-blockers. Although the plausible explanation of this precipitating event is the usage of β-blocker, we reviewed the previous published similar clinical reports and proposed other possible explanations and differential diagnosis. It is important to recognize this potential cardiovascular side-effect in patients administrated with topical and/or submucosal epinephrine. Drugs used to treat hypertension and/or arrhythmia needed to be appreciated.
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Affiliation(s)
- Yunqin Ren
- Department of Anesthesiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Yao Wang
- Department of Anesthesiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Hong Yan
- Department of Anesthesiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Liyong Chen
- Department of Anesthesiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Qingxiang Mao
- Department of Anesthesiology, Daping Hospital, Army Medical University, Chongqing, China
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15
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Liu D, Lin Y, Gong N, Xiao Z, Zhang F, Zhong X, Yi Z, Yang C, Zhang G, Ai J. Degree and duration of hypokalemia associated with peritonitis in patients undergoing peritoneal dialysis. Int J Clin Pract 2021; 75:e14188. [PMID: 33783932 DOI: 10.1111/ijcp.14188] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 03/25/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Hypokalemia (LK) was associated with peritonitis in peritoneal dialysis (PD) patients, while the role of its degree and duration have not been fully established. Here, we conducted a retrospective cohort study to identify the relationships of LK degree and duration with peritonitis in PD patients. METHODS A total of 602 PD patients in our department from Jan 1st, 2009 to Dec 31st, 2019 entered the last analysis. Data were collected from their medical records. Serum potassium (SK) levels, degree of hypokalemia, and duration of hypokalemia were analysed with peritonitis. The time association of hypokalemia and peritonitis was also analysed. RESULTS There were totally 320 (53.7%) and 123 (20.7%) patients who had ever suffered from LK and serious hypokalemia (SLK) in the cohort. Only 6.82% and 0.5% of patients had LK and SLK at baseline, while the incidence increased and kept in 25%-32% and 5.5%-8.2% after PD. Both LK (HR 1.437, 95% CI 1.014-2.038, P = .042) and SLK (HR 2.021, 95% CI 1.429-2.857, P < .001) did correlate to peritonitis after adjusted analyses, while only SLK remained the significance at each follow-up point. The LK/SLK durations were 6 (3-12) and 6 (3-6) months, and only longer SLK duration correlated with peritonitis after adjusted analyses. After categorised, those LK durations more than 6 months and SLK durations more than 3 months presented a significant association with peritonitis. Of the patients who suffered from both hypokalemia and peritonitis, 70.4% patients' LK times were earlier than peritonitis time, while most SLK times (62.7%) were later. SLK also correlated with combined endpoint. CONCLUSIONS Hypokalemia degree and duration were tightly associated with peritonitis. Hypokalemia might be a causal factor of peritonitis, while peritonitis might also aggravate hypokalemia. We should manage SK as much as possible and avoid hypokalemia, especially serious hypokalemia in clinic practice.
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Affiliation(s)
- Danyang Liu
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
- School of Nursing, Southern Medical University, Guangzhou, P.R. China
| | - Yanhong Lin
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Nirong Gong
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Zhiwen Xiao
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Fen Zhang
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Xiaohong Zhong
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Zhixiu Yi
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Cong Yang
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Guangqing Zhang
- Administrative Office, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Jun Ai
- State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
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16
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Muzurović E, Medenica S, Kalezić M, Pavlović S. Primary hyperparathyroidism associated with acquired long QT interval and ventricular tachycardia. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210016. [PMID: 34341183 PMCID: PMC8346179 DOI: 10.1530/edm-21-0016] [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: 05/19/2021] [Accepted: 07/13/2021] [Indexed: 12/19/2022] Open
Abstract
SUMMARY We present a 54-year-old patient admitted to the emergency department due to loss of consciousness. The initial ECG registered monomorphic ventricular extrasystoles and prolonged QT interval (QT corrected (QTc) >500 ms). Sustained ventricular tachycardia (VT) was registered on 24-h Holter ECG monitoring, which clinically was presented as a crisis of consciousness. Coronary angiography and other visualization methods were normal. Implantable cardioverter-defibrillator (ICD) implantation was planned for the purpose of secondary prevention of sudden cardiac death (SCD). Laboratory and hormonal analyzes revealed primary hyperparathyroidism (PHPT), chronic kidney disease, and hypokalemia. Neck ultrasound showed a 25 mm, sharply outlined homogenous tumor mass which was separated from thyroid gland (TG) and exerted a mild impression on lower parts of the left lobe. Dual wash technetium-99m sestamibi parathyroid scintigraphy with single-photon emission CT (SPECT)/CT also showed the uptake of tracer behind the lower half of the left lobe of the TG. Surgical treatment, lower left parathyroidectomy, was performed, and pathohistological analysis verified parathyroid adenoma. The patient was rhythmically and hemodynamically stable for 7 days after surgery, without additional complaints, and was discharged from the hospital. Timely diagnosis of PHPT, correct assessment and surgical treatment, did not lead our patient to unnecessary ICD implantation. Our case suggests an additional intertwining of electrolyte disorders and ventricular arrhythmias in PHPT and more importantly emphasizes the need for caution when indicating ICD, even in patients with the most serious life-threatening arrhythmias. LEARNING POINTS Electrolyte abnormalities in PHPT can have highly malignant consequences, and the occurrence of hypokalemia in the presence of hypercalcemia is underestimated in PHPT, and the consequences can be life-threatening. Although hypercalcemia causes shortened QT interval, concomitant severe hypokalemia may overcome hypercalcemia and prolong QT interval, even in the absence of structural heart disease or LQTS. Timely diagnosis of PHPT, correct assessment and surgical treatment, do not lead to unnecessary ICD implantation.
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Affiliation(s)
- Emir Muzurović
- Department of Internal Medicine, Endocrinology Section, Clinical Center of Montenegro, Podgorica, Montenegro
- Faculty of Medicine, University of Montenegro, Podgorica, Montenegro
| | - Sanja Medenica
- Department of Internal Medicine, Endocrinology Section, Clinical Center of Montenegro, Podgorica, Montenegro
- Faculty of Medicine, University of Montenegro, Podgorica, Montenegro
| | - Milovan Kalezić
- Department of Cardiology, Clinical Center of Montenegro, Podgorica, Montenegro
| | - Siniša Pavlović
- Pacemaker Center, Clinical Center of Serbia, Faculty of Medicine University of Belgrade, Belgrade, Serbia
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17
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Duarte Torres J, Marschall A, Fraile Sanz C, Biscotti Rodíl B, Del Castillo Carnevali H, Martí Sánchez D. Ventricular tachycardia secondary to thyrotoxic periodic paralysis: A case report. J Electrocardiol 2021; 67:107-109. [PMID: 34139616 DOI: 10.1016/j.jelectrocard.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/02/2021] [Accepted: 06/05/2021] [Indexed: 11/30/2022]
Abstract
Thyrotoxic periodic paralysis (TPP) is a rare but potentially life-threatening entity, which is characterized by sudden onset of muscle weakness and can in exceptional cases be associated with more severe symptoms, such as severe hypokalemia. We present the rare case of a young patient presenting with monomorphic ventricular tachycardia secondary to hypokalemia due to TPP. This case report highlights the importance of recognition of TPP as a rare cause of VT. A high index of suspicion is needed since signs of hyperthyroidism may be subtle. However, early diagnosis is crucial in order to avoid cardiovascular complications and improve outcomes.
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Affiliation(s)
- Juan Duarte Torres
- Department of Cardiology, Central Defense Hospital Gómez Ulla, Madrid, Spain
| | - Alexander Marschall
- Department of Cardiology, Central Defense Hospital Gómez Ulla, Madrid, Spain.
| | | | | | | | - David Martí Sánchez
- Department of Cardiology, Central Defense Hospital Gómez Ulla, Madrid, Spain
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18
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Clerx M, Mirams GR, Rogers AJ, Narayan SM, Giles WR. Immediate and Delayed Response of Simulated Human Atrial Myocytes to Clinically-Relevant Hypokalemia. Front Physiol 2021; 12:651162. [PMID: 34122128 PMCID: PMC8188899 DOI: 10.3389/fphys.2021.651162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022] Open
Abstract
Although plasma electrolyte levels are quickly and precisely regulated in the mammalian cardiovascular system, even small transient changes in K+, Na+, Ca2+, and/or Mg2+ can significantly alter physiological responses in the heart, blood vessels, and intrinsic (intracardiac) autonomic nervous system. We have used mathematical models of the human atrial action potential (AP) to explore the electrophysiological mechanisms that underlie changes in resting potential (Vr) and the AP following decreases in plasma K+, [K+]o, that were selected to mimic clinical hypokalemia. Such changes may be associated with arrhythmias and are commonly encountered in patients (i) in therapy for hypertension and heart failure; (ii) undergoing renal dialysis; (iii) with any disease with acid-base imbalance; or (iv) post-operatively. Our study emphasizes clinically-relevant hypokalemic conditions, corresponding to [K+]o reductions of approximately 1.5 mM from the normal value of 4 to 4.5 mM. We show how the resulting electrophysiological responses in human atrial myocytes progress within two distinct time frames: (i) Immediately after [K+]o is reduced, the K+-sensing mechanism of the background inward rectifier current (IK1) responds. Specifically, its highly non-linear current-voltage relationship changes significantly as judged by the voltage dependence of its region of outward current. This rapidly alters, and sometimes even depolarizes, Vr and can also markedly prolong the final repolarization phase of the AP, thus modulating excitability and refractoriness. (ii) A second much slower electrophysiological response (developing 5-10 minutes after [K+]o is reduced) results from alterations in the intracellular electrolyte balance. A progressive shift in intracellular [Na+]i causes a change in the outward electrogenic current generated by the Na+/K+ pump, thereby modifying Vr and AP repolarization and changing the human atrial electrophysiological substrate. In this study, these two effects were investigated quantitatively, using seven published models of the human atrial AP. This highlighted the important role of IK1 rectification when analyzing both the mechanisms by which [K+]o regulates Vr and how the AP waveform may contribute to "trigger" mechanisms within the proarrhythmic substrate. Our simulations complement and extend previous studies aimed at understanding key factors by which decreases in [K+]o can produce effects that are known to promote atrial arrhythmias in human hearts.
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Affiliation(s)
- Michael Clerx
- Centre for Mathematical Medicine and Biology, School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Gary R Mirams
- Centre for Mathematical Medicine and Biology, School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Albert J Rogers
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Sanjiv M Narayan
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Wayne R Giles
- Department of Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
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19
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Liu X, Adhikari BK, Chen T, Wang Y, Liu Q, Wang S. Ventricular fibrillation storm after revascularization of chronic total occlusion of the left anterior descending artery: is this reperfusion arrhythmia? J Int Med Res 2021; 49:300060521997618. [PMID: 33730893 PMCID: PMC8166392 DOI: 10.1177/0300060521997618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Electrical storm is a life-threatening emergency condition defined as three or more episodes of ventricular tachycardia or ventricular fibrillation (VF) within 24 hours requiring anti-tachycardia therapy, electrical cardioversion, or defibrillation. However, studies of the incidence of electrical storm after chronic total occlusion-percutaneous coronary intervention (CTO-PCI) are limited,7 and post-procedural VF after revascularization of CTO has not been described. The purpose of this article was to present a case of post-operative VF electrical storm after revascularization of CTO of the left anterior descending (LAD) artery to determine whether the electrical storm was caused by reperfusion arrhythmia or compromise of either branch vessels or the collateral circulation during intervention.
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Affiliation(s)
| | | | | | | | | | - Shudong Wang
- Department of Cardiology, the First Hospital of Jilin University, Changchun, Jilin Province, China
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20
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Affiliation(s)
| | - Mandeep R Mehra
- Brigham and Women’s Hospital and Harvard Medical School, USA
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21
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Jordaan P, Dumotier B, Traebert M, Miller PE, Ghetti A, Urban L, Abi-Gerges N. Cardiotoxic Potential of Hydroxychloroquine, Chloroquine and Azithromycin in Adult Human Primary Cardiomyocytes. Toxicol Sci 2021; 180:356-368. [PMID: 33483756 PMCID: PMC7928616 DOI: 10.1093/toxsci/kfaa194] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Substantial efforts have been recently committed to develop coronavirus disease-2019 (COVID-19) medications, and Hydroxychloroquine alone or in combination with Azithromycin has been promoted as a repurposed treatment. Although these drugs may increase cardiac toxicity risk, cardiomyocyte mechanisms underlying this risk remain poorly understood in humans. Therefore, we evaluated the proarrhythmia risk and inotropic effects of these drugs in the cardiomyocyte contractility-based model of the human heart. We found Hydroxychloroquine to have a low proarrhythmia risk, whereas Chloroquine and Azithromycin were associated with high risk. Hydroxychloroquine proarrhythmia risk changed to high with low level of K+, whereas high level of Mg2+ protected against proarrhythmic effect of high Hydroxychloroquine concentrations. Moreover, therapeutic concentration of Hydroxychloroquine caused no enhancement of elevated temperature-induced proarrhythmia. Polytherapy of Hydroxychloroquine plus Azithromycin and sequential application of these drugs were also found to influence proarrhythmia risk categorization. Hydroxychloroquine proarrhythmia risk changed to high when combined with Azithromycin at therapeutic concentration. However, Hydroxychloroquine at therapeutic concentration impacted the cardiac safety profile of Azithromycin and its proarrhythmia risk only at concentrations above therapeutic level. We also report that Hydroxychloroquine and Chloroquine, but not Azithromycin, decreased contractility while exhibiting multi-ion channel block features, and Hydroxychloroquine's contractility effect was abolished by Azithromycin. Thus, this study has the potential to inform clinical studies evaluating repurposed therapies, including those in the COVID-19 context. Additionally, it demonstrates the translational value of the human cardiomyocyte contractility-based model as a key early discovery path to inform decisions on novel therapies for COVID-19, malaria, and inflammatory diseases.
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Affiliation(s)
- Pierre Jordaan
- Chief Medical Officer and Patient Safety, Novartis AG, Basel, Switzerland
| | - Bérengère Dumotier
- Novartis Institutes for Biomedical Research, Preclinical Safety, Basel, Switzerland
| | - Martin Traebert
- Novartis Institutes for Biomedical Research, Preclinical Safety, Basel, Switzerland
| | - Paul E Miller
- AnaBios Corporation, San Diego, California 92109, USA
| | - Andre Ghetti
- AnaBios Corporation, San Diego, California 92109, USA
| | - Laszlo Urban
- Novartis Institutes for Biomedical Research, Preclinical Secondary Pharmacology, Cambridge, Massachusetts, USA
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22
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Adamczak M, Chudek J, Zejda J, Bartmańska M, Grodzicki T, Zdrojewski T, Wiecek A. Prevalence of hypokalemia in older persons: results from the PolSenior national survey. Eur Geriatr Med 2021; 12:981-987. [PMID: 33830482 PMCID: PMC8463376 DOI: 10.1007/s41999-021-00484-6] [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: 09/17/2020] [Accepted: 03/09/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Hypokalemia is one of the most common electrolyte disturbances in clinical practice. There are only a few epidemiological studies analyzing the occurrence of hypokalemia in older persons. The aim of the study was to determine the prevalence of hypokalemia in the Polish older population. METHODS Serum potassium concentration was estimated in 4654 participants (2270 females and 2384 males, mean age 76.5 [11.0] years), who participated in the PolSenior study. Hypokalemia was defined as serum potassium concentration below 3.5 mmol/L. Hypokalemia was found in 39 participants (0.84%) and was significantly more frequent among females (28 females = 1.23% and 11 males = 0.46%; p = 0.003). The prevalence of hypokalemia was not related to age. Among 3303 participants suffering from arterial hypertension, 1093 were treated with potassium-losing diuretics. RESULTS Hypokalemia was significantly more frequent among hypertensive than normotensive older participants (1.06 vs. 0.30% respectively; p = 0.007) and among hypertensive participants treated with potassium losing diuretics than ones untreated with these drugs (1.96 vs. 0.46% respectively; p < 0.001). In hypertensive participants, the prevalence of hypokalemia did not depend significantly on oral supplementation of potassium (1.92 and 0.98% respectively, NS). None of 81 participants using laxative agents presented hypokalemia. CONCLUSIONS This study demonstrates that: older age seems not to appear to be a significant risk factor of hypokalemia. Hypokalemia is more often found in the older hypertensive patients treated with potassium losing diuretics, and prevention of diuretic-induced hypokalemia with oral supplementation of potassium seems to be insufficient.
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Affiliation(s)
- Marcin Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Francuska Str. 20/24, 40-027, Katowice, Poland
| | - Jerzy Chudek
- Department of Internal Diseases and Oncological Chemotherapy, Medical University of Silesia in Katowice, Katowice, Poland
| | - Jan Zejda
- Department of Epidemiology, Medical University of Silesia in Katowice, Katowice, Poland
| | - Magdalena Bartmańska
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Francuska Str. 20/24, 40-027, Katowice, Poland.
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Cracow, Poland
| | - Tomasz Zdrojewski
- Department of Hypertension and Diabetology, Medical University of Gdansk, Gdansk, Poland
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Francuska Str. 20/24, 40-027, Katowice, Poland
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23
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Naseer M, Dafaalla M, Ahmed A, Mills MT. Paroxysmal narrow complex tachycardia secondary to hypokalaemic periodic paralysis. Br J Hosp Med (Lond) 2021; 82:1-3. [PMID: 33792378 DOI: 10.12968/hmed.2020.0464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Muhammad Naseer
- Department of Diabetes and Endocrinology, Bassetlaw Hospital, Doncaster and Bassetlaw, Teaching Hospitals NHS Foundation Trust, Worksop, UK
| | - Mohamed Dafaalla
- Department of Diabetes and Endocrinology, Bassetlaw Hospital, Doncaster and Bassetlaw, Teaching Hospitals NHS Foundation Trust, Worksop, UK
| | - Ali Ahmed
- Department of Diabetes and Endocrinology, Bassetlaw Hospital, Doncaster and Bassetlaw, Teaching Hospitals NHS Foundation Trust, Worksop, UK
| | - Mark T Mills
- Department of Diabetes and Endocrinology, Bassetlaw Hospital, Doncaster and Bassetlaw, Teaching Hospitals NHS Foundation Trust, Worksop, UK.,Department of Cardiology, The Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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24
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Tse G, Li KHC, Cheung CKY, Letsas KP, Bhardwaj A, Sawant AC, Liu T, Yan GX, Zhang H, Jeevaratnam K, Sayed N, Cheng SH, Wong WT. Arrhythmogenic Mechanisms in Hypokalaemia: Insights From Pre-clinical Models. Front Cardiovasc Med 2021; 8:620539. [PMID: 33614751 PMCID: PMC7887296 DOI: 10.3389/fcvm.2021.620539] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/13/2021] [Indexed: 12/21/2022] Open
Abstract
Potassium is the predominant intracellular cation, with its extracellular concentrations maintained between 3. 5 and 5 mM. Among the different potassium disorders, hypokalaemia is a common clinical condition that increases the risk of life-threatening ventricular arrhythmias. This review aims to consolidate pre-clinical findings on the electrophysiological mechanisms underlying hypokalaemia-induced arrhythmogenicity. Both triggers and substrates are required for the induction and maintenance of ventricular arrhythmias. Triggered activity can arise from either early afterdepolarizations (EADs) or delayed afterdepolarizations (DADs). Action potential duration (APD) prolongation can predispose to EADs, whereas intracellular Ca2+ overload can cause both EADs and DADs. Substrates on the other hand can either be static or dynamic. Static substrates include action potential triangulation, non-uniform APD prolongation, abnormal transmural repolarization gradients, reduced conduction velocity (CV), shortened effective refractory period (ERP), reduced excitation wavelength (CV × ERP) and increased critical intervals for re-excitation (APD-ERP). In contrast, dynamic substrates comprise increased amplitude of APD alternans, steeper APD restitution gradients, transient reversal of transmural repolarization gradients and impaired depolarization-repolarization coupling. The following review article will summarize the molecular mechanisms that generate these electrophysiological abnormalities and subsequent arrhythmogenesis.
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Affiliation(s)
- Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Ka Hou Christien Li
- Faculty of Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Aishwarya Bhardwaj
- Division of Cardiology, Department of Internal Medicine, State University of New York at Buffalo, Buffalo, NY, United States
| | - Abhishek C Sawant
- Division of Cardiology, Department of Internal Medicine, State University of New York at Buffalo, Buffalo, NY, United States
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Gan-Xin Yan
- Lankenau Institute for Medical Research and Lankenau Medical Center, Wynnewood, PA, United States
| | - Henggui Zhang
- School of Physics and Astronomy, The University of Manchester, Manchester, United Kingdom
| | - Kamalan Jeevaratnam
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Nazish Sayed
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Shuk Han Cheng
- Department of Biomedical Sciences, College of Veterinary Medicine and Life Science, City University of Hong Kong, Hong Kong, China.,State Key Laboratory of Marine Pollution (SKLMP), City University of Hong Kong, Hong Kong, China.,Department of Materials Science and Engineering, College of Science and Engineering, City University of Hong Kong, Hong Kong, China
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, China
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25
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Mareev VY, Garganeeva AA, Ageev FT, Arutunov GP, Begrambekova YL, Belenkov YN, Vasyuk YA, Galyavich AS, Gilarevsky SR, Glezer MG, Drapkina OM, Duplyakov DV, Kobalava ZD, Koziolova NA, Kuzheleva EA, Mareev YV, Ovchinnikov AG, Orlova YA, Perepech NB, Sitnikova MY, Skvortsov AA, Skibitskiy VV, Chesnikova AI. [The use of diuretics in chronic heart failure. Position paper of the Russian Heart Failure Society]. ACTA ACUST UNITED AC 2021; 60:13-47. [PMID: 33522467 DOI: 10.18087/cardio.2020.12.n1427] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 11/18/2022]
Abstract
The document focuses on key issues of diuretic therapy in CHF from the standpoint of current views on the pathogenesis of edema syndrome, its diagnosis, and characteristics of using diuretics in various clinical situations.
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Affiliation(s)
- V Yu Mareev
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | - A A Garganeeva
- "Research Institute for Cardiology", Siberian State Medical University, Tomsk National Research Medical Center, Russian Academy of Sciences
| | - F T Ageev
- Scientific Medical Research Center of Cardiology, Russia
| | - G P Arutunov
- Russian National Research Medical University named after Pirogov, Moscow
| | - Yu L Begrambekova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | - Yu N Belenkov
- Sechenov Moscow State Medical University, Moscow, Russia
| | - Yu A Vasyuk
- Moscow State Medical and Dental University named after Evdokimov, Moscow, Russia
| | | | - S R Gilarevsky
- Russian Medical Academy of Postgraduate Education, Moscow, Russia
| | - M G Glezer
- Sechenov Moscow State Medical University, Moscow, Russia
| | - O M Drapkina
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russia
| | - D V Duplyakov
- Samara Regional Clinical Cardiological Dispensary, Russia
| | - Zh D Kobalava
- Russian State University of Peoples' Friendship, Moscow, Russia
| | - N A Koziolova
- Federal State Budgetary Institution of Healthcare of Higher Education "Perm State Medical University named after Academician E.A. Wagner ", Russia
| | - E A Kuzheleva
- "Research Institute for Cardiology", Siberian State Medical University, Tomsk National Research Medical Center, Russian Academy of Sciences, Russia
| | - Yu V Mareev
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russia Robertson Centre for Biostatistics, Glasgow, Great Britain
| | | | - Ya A Orlova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | | | - M Yu Sitnikova
- Almazov National Medical Research Center, St. Petersburg, Russia
| | - A A Skvortsov
- Scientific Medical Research Center of Cardiology, Russia
| | - V V Skibitskiy
- Kuban State Medical University" of the Ministry of Health of the Russian Federation, Russia
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26
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Kimrey J, Vo T, Bertram R. Canard analysis reveals why a large Ca2+ window current promotes early afterdepolarizations in cardiac myocytes. PLoS Comput Biol 2020; 16:e1008341. [PMID: 33147207 PMCID: PMC7641359 DOI: 10.1371/journal.pcbi.1008341] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/14/2020] [Indexed: 12/19/2022] Open
Abstract
The pumping of blood through the heart is due to a wave of muscle contractions that are in turn due to a wave of electrical activity initiated at the sinoatrial node. At the cellular level, this wave of electrical activity corresponds to the sequential excitation of electrically coupled cardiac cells. Under some conditions, the normally-long action potentials of cardiac cells are extended even further by small oscillations called early afterdepolarizations (EADs) that can occur either during the plateau phase or repolarizing phase of the action potential. Hence, cellular EADs have been implicated as a driver of potentially lethal cardiac arrhythmias. One of the major determinants of cellular EAD production and repolarization failure is the size of the overlap region between Ca2+ channel activation and inactivation, called the window region. In this article, we interpret the role of the window region in terms of the fast-slow structure of a low-dimensional model for ventricular action potential generation. We demonstrate that the effects of manipulation of the size of the window region can be understood from the point of view of canard theory. We use canard theory to explain why enlarging the size of the window region elicits EADs and why shrinking the window region can eliminate them. We also use the canard mechanism to explain why some manipulations in the size of the window region have a stronger influence on cellular electrical behavior than others. This dynamical viewpoint gives predictive power that is beyond that of the biophysical explanation alone while also uncovering a common mechanism for phenomena observed in experiments on both atrial and ventricular cardiac cells.
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Affiliation(s)
- Joshua Kimrey
- Department of Mathematics, Florida State University, Tallahassee, Florida, United States of America
| | - Theodore Vo
- School of Mathematics, Monash University, Clayton, Victoria, Australia
| | - Richard Bertram
- Department of Mathematics, and Programs in Neuroscience and Biophysics, Florida State University, Tallahassee, Florida, United States of America
- * E-mail:
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27
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Xie Y, Han J, Liu J, Hao J, Zu X, Hao Y. A case of hypokalemia-induced bidirectional ventricular tachycardia. J Int Med Res 2020; 48:300060520971440. [PMID: 33213242 PMCID: PMC7686617 DOI: 10.1177/0300060520971440] [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] [Indexed: 11/23/2022] Open
Abstract
Background Bidirectional ventricular tachycardia (BVT) is a rare, but serious,
arrhythmia. Hypokalemia is commonly found in clinical practice, but
hypokalemia-induced BVT has rarely been reported. Case presentation A 74-year-old male patient with the symptoms of chest distress and
palpitations was admitted owing to frequent discharge of his implantable
cardioverter defibrillator (ICD) for 4 days. Before admission, the patient
experienced diarrhea after intake of crabs, and felt frequent discharge of
his ICD with a total of approximately 17 discharges in 4 days. He had no
history of digitalis use. The serum potassium level after admission was
3.1 mmol/L and an electrocardiogram was consistent with BVT. The diagnosis
was ventricular tachycardia, electrical storm, and hypokalemia. His
ventricular tachycardia was completely relieved after correction of
hypokalemia. Conclusions After correction of hypokalemia in this patient, the episode of BVT was
terminated and no recurrence of BVT was observed during long-term follow-up.
Our findings suggest the diagnosis of hypokalemia-induced BVT.
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Affiliation(s)
- Yanan Xie
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jingzhe Han
- Department of Neurology, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Jinming Liu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jie Hao
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiuguang Zu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yuming Hao
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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28
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Varró A, Tomek J, Nagy N, Virág L, Passini E, Rodriguez B, Baczkó I. Cardiac transmembrane ion channels and action potentials: cellular physiology and arrhythmogenic behavior. Physiol Rev 2020; 101:1083-1176. [PMID: 33118864 DOI: 10.1152/physrev.00024.2019] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cardiac arrhythmias are among the leading causes of mortality. They often arise from alterations in the electrophysiological properties of cardiac cells and their underlying ionic mechanisms. It is therefore critical to further unravel the pathophysiology of the ionic basis of human cardiac electrophysiology in health and disease. In the first part of this review, current knowledge on the differences in ion channel expression and properties of the ionic processes that determine the morphology and properties of cardiac action potentials and calcium dynamics from cardiomyocytes in different regions of the heart are described. Then the cellular mechanisms promoting arrhythmias in congenital or acquired conditions of ion channel function (electrical remodeling) are discussed. The focus is on human-relevant findings obtained with clinical, experimental, and computational studies, given that interspecies differences make the extrapolation from animal experiments to human clinical settings difficult. Deepening the understanding of the diverse pathophysiology of human cellular electrophysiology will help in developing novel and effective antiarrhythmic strategies for specific subpopulations and disease conditions.
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Affiliation(s)
- András Varró
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary.,MTA-SZTE Cardiovascular Pharmacology Research Group, Hungarian Academy of Sciences, Szeged, Hungary
| | - Jakub Tomek
- Department of Computer Science, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - Norbert Nagy
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary.,MTA-SZTE Cardiovascular Pharmacology Research Group, Hungarian Academy of Sciences, Szeged, Hungary
| | - László Virág
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Elisa Passini
- Department of Computer Science, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - Blanca Rodriguez
- Department of Computer Science, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - István Baczkó
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary
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29
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Skogestad J, Aronsen JM, Tovsrud N, Wanichawan P, Hougen K, Stokke MK, Carlson CR, Sjaastad I, Sejersted OM, Swift F. Coupling of the Na+/K+-ATPase to Ankyrin B controls Na+/Ca2+ exchanger activity in cardiomyocytes. Cardiovasc Res 2020; 116:78-90. [PMID: 30949686 DOI: 10.1093/cvr/cvz087] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/22/2019] [Accepted: 04/03/2019] [Indexed: 01/28/2023] Open
Abstract
AIMS Ankyrin B (AnkB) is an adaptor protein that assembles Na+/K+-ATPase (NKA) and Na+/Ca2+ exchanger (NCX) in the AnkB macromolecular complex. Loss-of-function mutations in AnkB cause the AnkB syndrome in humans, characterized by ventricular arrhythmias and sudden cardiac death. It is unclear to what extent NKA binding to AnkB allows regulation of local Na+ and Ca2+ domains and hence NCX activity. METHODS AND RESULTS To investigate the role of NKA binding to AnkB in cardiomyocytes, we synthesized a disruptor peptide (MAB peptide) and its AnkB binding ability was verified by pulldown experiments. As opposed to control, the correlation between NKA and NCX currents was abolished in adult rat ventricular myocytes dialyzed with MAB peptide, as well as in cardiomyocytes from AnkB+/- mice. Disruption of NKA from AnkB (with MAB peptide) increased NCX-sensed cytosolic Na+ concentration, reduced Ca2+ extrusion through NCX, and increased frequency of Ca2+ sparks and Ca2+ waves without concomitant increase in Ca2+ transient amplitude or SR Ca2+ load, suggesting an effect in local Ca2+ domains. Selective inhibition of the NKAα2 isoform abolished both the correlation between NKA and NCX currents and the increased rate of Ca2+ sparks and waves following NKA/AnkB disruption, suggesting that an AnkB/NKAα2/NCX domain controls Ca2+ fluxes in cardiomyocytes. CONCLUSION NKA binding to AnkB allows ion regulation in a local domain, and acute disruption of the NKA/AnkB interaction using disruptor peptides lead to increased rate of Ca2+ sparks and waves. The functional effects were mediated through the NKAα2 isoform. Disruption of the AnkB/NKA/NCX domain could be an important pathophysiological mechanism in the AnkB syndrome.
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Affiliation(s)
- Jonas Skogestad
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Ullevål, N-0407 Oslo, Norway.,KG Jebsen Cardiac Research Centre and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Jan Magnus Aronsen
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Ullevål, N-0407 Oslo, Norway.,Bjørknes College, Oslo, Norway
| | - Nils Tovsrud
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Ullevål, N-0407 Oslo, Norway.,KG Jebsen Cardiac Research Centre and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Pimthanya Wanichawan
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Ullevål, N-0407 Oslo, Norway.,KG Jebsen Cardiac Research Centre and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Karina Hougen
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Ullevål, N-0407 Oslo, Norway.,KG Jebsen Cardiac Research Centre and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Mathis Korseberg Stokke
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Ullevål, N-0407 Oslo, Norway.,KG Jebsen Cardiac Research Centre and Center for Heart Failure Research, University of Oslo, Oslo, Norway.,Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Cathrine Rein Carlson
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Ullevål, N-0407 Oslo, Norway.,KG Jebsen Cardiac Research Centre and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Ivar Sjaastad
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Ullevål, N-0407 Oslo, Norway.,KG Jebsen Cardiac Research Centre and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Ole Mathias Sejersted
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Ullevål, N-0407 Oslo, Norway.,KG Jebsen Cardiac Research Centre and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Fredrik Swift
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Ullevål, N-0407 Oslo, Norway.,KG Jebsen Cardiac Research Centre and Center for Heart Failure Research, University of Oslo, Oslo, Norway.,Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
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30
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Bilha S, Mitu O, Teodoriu L, Haba C, Preda C. Thyrotoxic Periodic Paralysis-A Misleading Challenge in the Emergency Department. Diagnostics (Basel) 2020; 10:E316. [PMID: 32443393 PMCID: PMC7277936 DOI: 10.3390/diagnostics10050316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022] Open
Abstract
Despite its' life-threatening potential due to cardiac severe dysrhythmia in the context of severe hypokalemia, thyrotoxic periodic paralysis (TPP) often goes unrecognized. Although classically confined to young Asian men, it can occur irrespective of age, sex, and race. We report a short series of three cases of TPP as first presentation of Graves' disease in a young Caucasian male and in two Caucasian elderly and middle-aged women, respectively. The first patient developed malignant ventricular arrhythmias due to severe hypokalemia and was defibrillated, with recovery after prompt potassium correction and administration of antithyroid agents and propranolol. The other two cases developed persistent hypokalemia despite adequate potassium chloride (KCl) repletion, with slow recovery of motor deficit and serum potassium normalization up to day 5. In the first case, long-term euthyroid state was achieved via total thyroidectomy due to the presence of a suspicious nodule that proved to be malignant. In the other two cases, medical treatment was the choice of therapy for thyrotoxicosis. None experienced recurrent TPP. Thyroid hormone evaluation is mandatory in the presence of hypokalemic paralysis, even in the absence of clinical signs of thyrotoxicosis. If TPP is confirmed, initial therapy should comprise antithyroid drugs and propranolol, besides hypokalemia correction.
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Affiliation(s)
- Stefana Bilha
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700111 Iasi, Romania; (S.B.); (C.P.)
| | - Ovidiu Mitu
- Cardiology Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700111 Iasi, Romania;
| | - Laura Teodoriu
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700111 Iasi, Romania; (S.B.); (C.P.)
| | - Cristian Haba
- Cardiology Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700111 Iasi, Romania;
| | - Cristina Preda
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700111 Iasi, Romania; (S.B.); (C.P.)
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31
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Tazmini K, Frisk M, Lewalle A, Laasmaa M, Morotti S, Lipsett DB, Manfra O, Skogestad J, Aronsen JM, Sejersted OM, Sjaastad I, Edwards AG, Grandi E, Niederer SA, Øie E, Louch WE. Hypokalemia Promotes Arrhythmia by Distinct Mechanisms in Atrial and Ventricular Myocytes. Circ Res 2020; 126:889-906. [PMID: 32070187 PMCID: PMC7098435 DOI: 10.1161/circresaha.119.315641] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
RATIONALE Hypokalemia occurs in up to 20% of hospitalized patients and is associated with increased incidence of ventricular and atrial fibrillation. It is unclear whether these differing types of arrhythmia result from direct and perhaps distinct effects of hypokalemia on cardiomyocytes. OBJECTIVE To investigate proarrhythmic mechanisms of hypokalemia in ventricular and atrial myocytes. METHODS AND RESULTS Experiments were performed in isolated rat myocytes exposed to simulated hypokalemia conditions (reduction of extracellular [K+] from 5.0 to 2.7 mmol/L) and supported by mathematical modeling studies. Ventricular cells subjected to hypokalemia exhibited Ca2+ overload and increased generation of both spontaneous Ca2+ waves and delayed afterdepolarizations. However, similar Ca2+-dependent spontaneous activity during hypokalemia was only observed in a minority of atrial cells that were observed to contain t-tubules. This effect was attributed to close functional pairing of the Na+-K+ ATPase and Na+-Ca2+ exchanger proteins within these structures, as reduction in Na+ pump activity locally inhibited Ca2+ extrusion. Ventricular myocytes and tubulated atrial myocytes additionally exhibited early afterdepolarizations during hypokalemia, associated with Ca2+ overload. However, early afterdepolarizations also occurred in untubulated atrial cells, despite Ca2+ quiescence. These phase-3 early afterdepolarizations were rather linked to reactivation of nonequilibrium Na+ current, as they were rapidly blocked by tetrodotoxin. Na+ current-driven early afterdepolarizations in untubulated atrial cells were enabled by membrane hyperpolarization during hypokalemia and short action potential configurations. Brief action potentials were in turn maintained by ultra-rapid K+ current (IKur); a current which was found to be absent in tubulated atrial myocytes and ventricular myocytes. CONCLUSIONS Distinct mechanisms underlie hypokalemia-induced arrhythmia in the ventricle and atrium but also vary between atrial myocytes depending on subcellular structure and electrophysiology.
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Affiliation(s)
- Kiarash Tazmini
- From the Institute for Experimental Medical Research, Oslo University Hospital (K.T., M.F., M.L., D.B.L., O.M., J.S., J.M.A., O.M.S., I.S., W.E.L.), University of Oslo, Norway
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway (K.T., E.Ø.)
| | - Michael Frisk
- From the Institute for Experimental Medical Research, Oslo University Hospital (K.T., M.F., M.L., D.B.L., O.M., J.S., J.M.A., O.M.S., I.S., W.E.L.), University of Oslo, Norway
- KG Jebsen Center for Cardiac Research (M.F., M.L., O.M., I.S., W.E.L.), University of Oslo, Norway
| | - Alexandre Lewalle
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (A.L., S.A.N.)
| | - Martin Laasmaa
- From the Institute for Experimental Medical Research, Oslo University Hospital (K.T., M.F., M.L., D.B.L., O.M., J.S., J.M.A., O.M.S., I.S., W.E.L.), University of Oslo, Norway
- KG Jebsen Center for Cardiac Research (M.F., M.L., O.M., I.S., W.E.L.), University of Oslo, Norway
| | - Stefano Morotti
- Department of Pharmacology, School of Medicine, University of California Davis (S.M., A.G.E., E.G.)
| | - David B. Lipsett
- From the Institute for Experimental Medical Research, Oslo University Hospital (K.T., M.F., M.L., D.B.L., O.M., J.S., J.M.A., O.M.S., I.S., W.E.L.), University of Oslo, Norway
| | - Ornella Manfra
- From the Institute for Experimental Medical Research, Oslo University Hospital (K.T., M.F., M.L., D.B.L., O.M., J.S., J.M.A., O.M.S., I.S., W.E.L.), University of Oslo, Norway
- KG Jebsen Center for Cardiac Research (M.F., M.L., O.M., I.S., W.E.L.), University of Oslo, Norway
| | - Jonas Skogestad
- From the Institute for Experimental Medical Research, Oslo University Hospital (K.T., M.F., M.L., D.B.L., O.M., J.S., J.M.A., O.M.S., I.S., W.E.L.), University of Oslo, Norway
| | - Jan M. Aronsen
- From the Institute for Experimental Medical Research, Oslo University Hospital (K.T., M.F., M.L., D.B.L., O.M., J.S., J.M.A., O.M.S., I.S., W.E.L.), University of Oslo, Norway
- Bjørknes College, Oslo, Norway (J.M.A.)
| | - Ole M. Sejersted
- From the Institute for Experimental Medical Research, Oslo University Hospital (K.T., M.F., M.L., D.B.L., O.M., J.S., J.M.A., O.M.S., I.S., W.E.L.), University of Oslo, Norway
| | - Ivar Sjaastad
- From the Institute for Experimental Medical Research, Oslo University Hospital (K.T., M.F., M.L., D.B.L., O.M., J.S., J.M.A., O.M.S., I.S., W.E.L.), University of Oslo, Norway
- KG Jebsen Center for Cardiac Research (M.F., M.L., O.M., I.S., W.E.L.), University of Oslo, Norway
| | - Andrew G. Edwards
- Department of Pharmacology, School of Medicine, University of California Davis (S.M., A.G.E., E.G.)
| | - Eleonora Grandi
- Department of Pharmacology, School of Medicine, University of California Davis (S.M., A.G.E., E.G.)
| | - Steven A. Niederer
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (A.L., S.A.N.)
| | - Erik Øie
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway (K.T., E.Ø.)
| | - William E. Louch
- From the Institute for Experimental Medical Research, Oslo University Hospital (K.T., M.F., M.L., D.B.L., O.M., J.S., J.M.A., O.M.S., I.S., W.E.L.), University of Oslo, Norway
- KG Jebsen Center for Cardiac Research (M.F., M.L., O.M., I.S., W.E.L.), University of Oslo, Norway
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Aroke EN, Nkemazeh RZ. Perianesthesia Implications and Considerations for Drug-Induced QT Interval Prolongation. J Perianesth Nurs 2020; 35:104-111. [PMID: 31955897 DOI: 10.1016/j.jopan.2019.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/21/2019] [Accepted: 09/21/2019] [Indexed: 12/19/2022]
Abstract
Prolongation of the QT interval can predispose patients to fatal arrhythmias such as torsade de pointes. While arrhythmias can occur spontaneously in patients with a genetic predisposition, drugs such as ondansetron and droperidol, which are frequently used in the perioperative period, have been implicated in the prolongation of the QT interval. As the list of medications that cause QT prolongation grows, anesthesia providers and perioperative nurses must be informed regarding the importance of the QT interval. This article reviews the physiology and measurement of the QT interval, the risk factors of QT prolongation, the mechanism of drug-induced QT prolongation, and perioperative considerations for patient care.
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Affiliation(s)
- Edwin N Aroke
- Nurse Anesthesia Track, School of Nursing, The University of Alabama at Birmingham, Birmingham, AL.
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Abstract
Hypertension is the most common cardiovascular risk factor and underlies heart failure, coronary artery disease, stroke, and chronic kidney disease. Hypertensive heart disease can manifest as cardiac arrhythmias. Supraventricular and ventricular arrhythmias may occur in the hypertensive patients. Atrial fibrillation and hypertension contribute to an increased risk of stroke. Some antihypertensive drugs predispose to electrolyte abnormalities, which may result in atrial and ventricular arrhythmias. A multipronged strategy involving appropriate screening, aggressive lifestyle modifications, and optimal pharmacotherapy can result in improved blood pressure control and prevent the onset or delay progression of heart failure, coronary artery disease, and cardiac arrhythmias.
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Affiliation(s)
- Muhammad R Afzal
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - Salvatore Savona
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - Omar Mohamed
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - Aayah Mohamed-Osman
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - Steven J Kalbfleisch
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA.
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Ghalyoun BA, Khaddash I, Shamoon D, Shaaban H, Hanna M, Tiyyagura S, Ismail M. A rare case of hypokalemic ventricular tachycardia in a patient with thyrotoxic periodic paralysis. Int J Crit Illn Inj Sci 2019; 9:199-202. [PMID: 31879609 PMCID: PMC6927127 DOI: 10.4103/ijciis.ijciis_39_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/14/2019] [Accepted: 09/20/2019] [Indexed: 11/04/2022] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a potentially fatal complication of hyperthyroidism, characterized by recurrent muscle paralysis and hypokalemia. We present a case of a 32-year-old apparently healthy male patient, who presented with acute paraparesis associated with hypokalemia (K: 1.6 mmol/L), complicated by ventricular tachycardia (VT). Advanced cardiac life support was initiated with an amiodarone infusion, and eventually QRS complex narrowed and wide complex tachycardia resolved. Intravenous potassium chloride (KCl) 40 mEq over 2-3 h and oral KCL 40 mEq were administered to treat the electrolyte imbalance. Patient paralysis was quickly reversed; motor function was regained with movement of the lower extremities. This case highlights the importance of early recognition and prompt treatment of TPP as a differential diagnosis for muscle weakness, especially in the setting of severe hypokalemia. It is important to pay attention to the possibility of the development of lethal VT associated with hypokalemia in the setting of hyperthyroidism and thyrotoxic paralysis.
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Affiliation(s)
- Bader Abu Ghalyoun
- Department of Cardiology, St. Joseph's Regional Medical Center, Affiliate of New York Medical College of Medicine, Paterson, Newark, NJ, USA
| | - Ibrahim Khaddash
- Department of Cardiology, St. Joseph's Regional Medical Center, Affiliate of New York Medical College of Medicine, Paterson, Newark, NJ, USA
| | - Dema Shamoon
- Department of Cardiology, St. Joseph's Regional Medical Center, Affiliate of New York Medical College of Medicine, Paterson, Newark, NJ, USA
| | - Hamid Shaaban
- Department of Internal Medicine, St. Michael's Medical Center, Affiliate of New York Medical College of Medicine, Newark, NJ, USA
| | - Michael Hanna
- Department of Cardiology, St. Joseph's Regional Medical Center, Affiliate of New York Medical College of Medicine, Paterson, Newark, NJ, USA
| | - Satish Tiyyagura
- Department of Cardiology, St. Joseph's Regional Medical Center, Affiliate of New York Medical College of Medicine, Paterson, Newark, NJ, USA
| | - Mourad Ismail
- Department of Critical Care, St. Joseph's Regional Medical Center, Affiliate of New York Medical College of Medicine, Paterson, Newark, NJ, USA
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Prado NJ, Egan Beňová T, Diez ER, Knezl V, Lipták B, Ponce Zumino AZ, Llamedo-Soria M, Szeiffová Bačová B, Miatello RM, Tribulová N. Melatonin receptor activation protects against low potassium-induced ventricular fibrillation by preserving action potentials and connexin-43 topology in isolated rat hearts. J Pineal Res 2019; 67:e12605. [PMID: 31408542 DOI: 10.1111/jpi.12605] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 07/27/2019] [Accepted: 08/05/2019] [Indexed: 12/22/2022]
Abstract
Hypokalemia prolongs the QRS and QT intervals, deteriorates intercellular coupling, and increases the risk for arrhythmia. Melatonin preserves gap junctions and shortens action potential as potential antiarrhythmic mechanisms, but its properties under hypokalemia remain unknown. We hypothesized that melatonin protects against low potassium-induced arrhythmias through the activation of its receptors, resulting in action potential shortening and connexin-43 preservation. After stabilization in Krebs-Henseleit solution (4.5 mEq/L K+ ), isolated hearts from Wistar rats underwent perfusion with low-potassium (1 mEq/L) solution and melatonin (100 μmol/L), a melatonin receptor blocker (luzindole, 5 μmol/L), melatonin + luzindole or vehicle. The primary endpoint of the study was the prevention of ventricular fibrillation. Electrocardiography was used, and epicardial action potentials and heart function were measured and analyzed. The ventricular expression, dephosphorylation, and distribution of connexin-43 were examined. Melatonin reduced the incidence of low potassium-induced ventricular fibrillation from 100% to 59%, delayed the occurrence of ventricular fibrillation and induced a faster recovery of sinus rhythm during potassium restitution. Melatonin prevented QRS widening, action potential activation delay, and the prolongation of action potential duration at 50% of repolarization. Other ECG and action potential parameters, the left ventricular developed pressure, and nonsustained ventricular arrhythmias did not differ among groups. Melatonin prevented connexin-43 dephosphorylation and its abnormal topology (lateralization). Luzindole abrogated the protective effects of melatonin on electrophysiological properties and connexin-43 misdistribution. Our results indicate that melatonin receptor activation protects against low potassium-induced ventricular fibrillation, shortens action potential duration, preserves ventricular electrical activation, and prevents acute changes in connexin-43 distribution. All of these properties make melatonin a remarkable antifibrillatory agent.
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Affiliation(s)
- Natalia Jorgelina Prado
- Instituto de Medicina y Biología Experimental de Cuyo, Consejo Nacional de Investigaciones Científicas y Técnicas, Mendoza, Argentina
| | - Tamara Egan Beňová
- Center of Experimental Medicine, Slovak Academy of Sciences, Institute for Heart Research, Bratislava, Slovakia
| | - Emiliano Raúl Diez
- Instituto de Medicina y Biología Experimental de Cuyo, Consejo Nacional de Investigaciones Científicas y Técnicas, Mendoza, Argentina
- Instituto de Fisiología, Facultad de Ciencias Médicas, Universidad Nacional de Cuyo, Mendoza, Argentina
| | - Vladimír Knezl
- Center of Experimental Medicine, Slovak Academy of Sciences, Institute of Experimental Pharmacology and Toxicology, Bratislava, Slovakia
| | - Boris Lipták
- Center of Experimental Medicine, Slovak Academy of Sciences, Institute of Experimental Pharmacology and Toxicology, Bratislava, Slovakia
| | - Amira Zulma Ponce Zumino
- Instituto de Medicina y Biología Experimental de Cuyo, Consejo Nacional de Investigaciones Científicas y Técnicas, Mendoza, Argentina
- Instituto de Fisiología, Facultad de Ciencias Médicas, Universidad Nacional de Cuyo, Mendoza, Argentina
| | - Mariano Llamedo-Soria
- Department of Electronic Engineering, Universidad Tecnológica Nacional, Buenos Aires, Argentina
| | - Barbara Szeiffová Bačová
- Center of Experimental Medicine, Slovak Academy of Sciences, Institute for Heart Research, Bratislava, Slovakia
| | - Roberto Miguel Miatello
- Instituto de Medicina y Biología Experimental de Cuyo, Consejo Nacional de Investigaciones Científicas y Técnicas, Mendoza, Argentina
- Instituto de Fisiología, Facultad de Ciencias Médicas, Universidad Nacional de Cuyo, Mendoza, Argentina
| | - Narcisa Tribulová
- Center of Experimental Medicine, Slovak Academy of Sciences, Institute for Heart Research, Bratislava, Slovakia
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Adler C, Schregel F, Heller T, Hellmich M, Adler J, Reuter H. Malignant Arrhythmias During Induction of Target Temperature Management After Cardiac Arrest. Ther Hypothermia Temp Manag 2019; 10:229-236. [PMID: 31560612 DOI: 10.1089/ther.2019.0025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim of this study was to evaluate the incidence and determinants of malignant arrhythmias (MA) in patients with shock following out-of-hospital cardiac arrest (OHCA) treated with targeted temperature management. Risk factors for the development of MA were prospectively analyzed in patients after OHCA. MA were defined as ventricular tachycardia or fibrillation with a duration >30 seconds, which had to be terminated by defibrillation. All patients were treated with therapeutic hypothermia for 24 hours. Demographics, OHCA details, interventions, and intensive care unit (ICU) treatment were recorded. A total of 55 patients were included, 11 (20%) of whom developed MA during the ICU stay. All MA occurred within the first 18 hours after admission. Patients who developed MA showed a stronger decrease in body temperature (Δ -2.4°C ± 0.8°C vs. Δ -1.3°C ± 1.3°C; p = 0.016) and in serum potassium levels (Δ -0.9 ± 1 mmol/L vs. Δ -0.3 ± 0.6 mmol/L; p = 0.037) during the cooling period compared with patients without MA. In the multivariable analysis, fast temperature decline as well as lower potassium levels were associated with MA. In addition, higher number of shocks during resuscitation and higher ICU epinephrine use were independent predictors of MA in patients with OHCA. The use of epinephrine as well as hypokalemia in context with intense cooling may increase the incidence of MA in patients with shock after cardiac arrest. Therefore, these therapeutic strategies should be applied with caution in this vulnerable group of patients.
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Affiliation(s)
- Christoph Adler
- Department of Internal Medicine III, Division of Cardiology, Pneumology, Angiology and Intensive Care, University of Cologne, Cologne, Germany
| | - Felix Schregel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Tobias Heller
- Department of Cardiothoracic Surgery, Heart Center of the University of Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics Epidemiology, University of Cologne, Cologne, Germany
| | - Joana Adler
- Department of Internal Medicine III, Division of Cardiology, Pneumology, Angiology and Intensive Care, University of Cologne, Cologne, Germany
| | - Hannes Reuter
- Department of Internal Medicine III, Division of Cardiology, Pneumology, Angiology and Intensive Care, University of Cologne, Cologne, Germany.,Department of Internal Medicine and Cardiology, Ev. Klinikum Köln-Weyertal, Cologne, Germany
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Eriguchi R, Obi Y, Soohoo M, Rhee CM, Kovesdy CP, Kalantar-Zadeh K, Streja E. Racial and Ethnic Differences in Mortality Associated with Serum Potassium in Incident Peritoneal Dialysis Patients. Am J Nephrol 2019; 50:361-369. [PMID: 31522173 PMCID: PMC6856395 DOI: 10.1159/000502998] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/25/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Abnormalities in serum potassium are risk factors for sudden cardiac death and arrhythmias among dialysis patients. Although a previous study in hemodialysis patients has shown that race/ethnicity may impact the relationship between serum potassium and mortality, the relationship remains unclear among peritoneal dialysis (PD) patients where the dynamics of serum potassium is more stable. METHODS Among 17,664 patients who started PD between January 1, 2007 and December 31, 2011 in a large US dialysis organization, we evaluated the association of serum potassium levels with all-cause and arrhythmia-related deaths across race/ethnicity using time-dependent Cox models with adjustments for demographics. We also used restricted cubic spline functions for serum potassium levels to explore non-linear associations. RESULTS Baseline serum potassium levels were the highest among Hispanics (4.2 ± 0.7 mEq/L) and lowest among non-Hispanic blacks (4.0 ± 0.7 mEq/L). Among 2,949 deaths during the follow-up of median 2.2 (interquartile ranges 1.3-3.2) years, 683 (23%) were arrhythmia-related deaths. Overall, both hyperkalemia and hypokalemia (i.e., serum potassium levels >5.0 and <3.5 mEq/L, respectively) were associated with higher all-cause and arrhythmia-related mortality. In a stratified analysis according to race/ethnicity, the association of hypokalemia with all-cause and arrhythmia-related mortality was consistent with an attenuation for arrhythmia-related mortality in non-Hispanic blacks. Hyperkalemia was associated with all-cause and arrhythmia-related mortality in non-Hispanic whites and non-Hispanic blacks, but no association was observed in Hispanics. CONCLUSION Among incident PD patients, hypokalemia was consistently associated with all-cause and arrhythmia-related deaths irrespective of race/ethnicity. However, while hyperkalemia was associated with both death outcomes in non-Hispanic blacks and whites, it was not associated with either death outcome in Hispanic patients. Further studies are needed to demonstrate whether different strategies should be followed for the management of serum potassium levels according to race/ethnicity.
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Affiliation(s)
- Rieko Eriguchi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
- Long Beach Veterans Affairs Healthcare System, Long Beach, California, USA
- Department Epidemiology, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA,
- Long Beach Veterans Affairs Healthcare System, Long Beach, California, USA,
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Samanta R, Chan C, Chauhan VS. Arrhythmias and Sudden Cardiac Death in End Stage Renal Disease: Epidemiology, Risk Factors, and Management. Can J Cardiol 2019; 35:1228-1240. [DOI: 10.1016/j.cjca.2019.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/23/2019] [Accepted: 05/07/2019] [Indexed: 11/17/2022] Open
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Rodriguez AP, Badiye A, Lambrakos LK, Ghodsizad A, Myerburg RJ, Goldberger JJ. Refractory ventricular tachycardia storm associated with severe hypokalemia in Fanconi syndrome. HeartRhythm Case Rep 2019; 5:374-378. [PMID: 31341780 PMCID: PMC6630180 DOI: 10.1016/j.hrcr.2019.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Alex P Rodriguez
- Cardiovascular Division, Miller School of Medicine, University of Miami, Miami, Florida
| | - Amit Badiye
- Cardiovascular Division, Miller School of Medicine, University of Miami, Miami, Florida
| | - Litsa K Lambrakos
- Cardiovascular Division, Miller School of Medicine, University of Miami, Miami, Florida
| | - Ali Ghodsizad
- Cardiothoracic Surgery Division, Miller School of Medicine, University of Miami, Miami, Florida
| | - Robert J Myerburg
- Cardiovascular Division, Miller School of Medicine, University of Miami, Miami, Florida
| | - Jeffrey J Goldberger
- Cardiovascular Division, Miller School of Medicine, University of Miami, Miami, Florida
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40
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Oshita K, Kozasa Y, Nakagawa Y, Kuwabara Y, Kuwahara K, Nakagawa T, Nakashima N, Hiraki T, Takano M. Overexpression of the HCN2 channel increases the arrhythmogenicity induced by hypokalemia. J Physiol Sci 2019; 69:653-660. [PMID: 31087220 PMCID: PMC6583697 DOI: 10.1007/s12576-019-00684-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 04/30/2019] [Indexed: 12/19/2022]
Abstract
Hypokalemia, an abnormally low level of potassium (K+), is a electrolyte imbalance that commonly occurs in heart failure patients. Hypokalemia is well known to induce lethal ventricular arrhythmia. However, the effects of hypokalemia in failing hearts that have undergone electrophysiological remodeling, i.e., the reactivation of fetal-type ion channels, remain unexplored. We have examined the effect of hypokalemia in the myocytes of transgenic mice overexpressing the hyperpolarization-activated, cyclic nucleotide-sensitive (HCN) channel in the heart (HCN2-Tg mice). Perfusion with a mild hypokalemic solution containing 3 mM K+ induced ectopic ventricular automaticity in 55.0% of HCN2-Tg mouse myocytes. In the remaining HCN2-Tg mouse myocytes, the resting membrane potential (RMP) was more depolarized than that of wild-type myocytes subjected to the same treatment and could also be hyperpolarized by an HCN channel blocker. We conclude that in hypokalemia in our mice model, the HCN2 channel was constitutively activated at the hyperpolarized RMP, thereby destabilizing the electrophysiological activity of ventricular myocytes.
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Affiliation(s)
- Kensuke Oshita
- Department of Physiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, 830-0011, Japan.,Department of Anesthesiology, Kurume University School of Medicine, Kurume, Japan
| | - Yuko Kozasa
- Department of Physiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, 830-0011, Japan.,Department of Anesthesiology, Kurume University School of Medicine, Kurume, Japan
| | - Yasuaki Nakagawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshihiro Kuwabara
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Taku Nakagawa
- Department of Physiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, 830-0011, Japan
| | - Noriyuki Nakashima
- Department of Physiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, 830-0011, Japan
| | - Teruyuki Hiraki
- Department of Anesthesiology, Kurume University School of Medicine, Kurume, Japan
| | - Makoto Takano
- Department of Physiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, 830-0011, Japan.
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41
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Tsai IH, Su YJ. Thyrotoxic periodic paralysis with ventricular tachycardia. J Electrocardiol 2019; 54:93-95. [PMID: 30965211 DOI: 10.1016/j.jelectrocard.2019.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 03/23/2019] [Accepted: 04/03/2019] [Indexed: 02/07/2023]
Abstract
A 47-year-old man presented to our emergency department (ED) with limbs weakness for 2 h. His heart rate was 127 beats per minute and blood pressure was 95/49 mm Hg. He found weakness of limbs after 4-h sleep. Physical examinations revealed that the muscle strength of upper limbs is 3/5, and lower limbs are 2/5. Electrocardiogram (ECG) revealed wide QRS complex, monomorphic ventricular tachycardia (VT) with ST-segment depression and long QT interval. Serum potassium level was extremely low as 1.0 mEq/L. This led to periodic hypokalemic paralysis. Due to severe hypokalemia with possible atrioventricular block, the patient was admitted to the intensive care unit. During hospitalization, his potassium level returned to 5.1 mEq/L on the first day. He had a low level of thyroid stimulating hormone (TSH) of <0.03 micro-IU/mL (normal range: 0.25-4.00) and a high free thyroxine (T4) level of 2.43 ng/dL (normal range: 0.89-1.79 ng/dL). Therefore, hyperthyroidism was diagnosed, and 5 mg of methimazole was administered twice a day. The patient was discharged on the seventh day after admission. The final diagnosis is thyrotoxic periodic paralysis (TPP), also as known as nocturnal paralysis or night palsy.
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Affiliation(s)
- I-Hsun Tsai
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yu-Jang Su
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan.
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42
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Legere RM, Jung S, Groover ES. ECG of the Month. J Am Vet Med Assoc 2019; 254:591-594. [DOI: 10.2460/javma.254.5.591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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43
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Abstract
Hypokalemia is one of the most common electrolyte disturbances in the clinic and it can increase the risk of life-threatening arrhythmias. Electrocardiographic characteristics associated with hypokalemia include dynamic changes in T-wave morphology, ST-segment depression, and U waves, which are often best seen in the mid-precordial leads (V2–V4). The PR interval can also be prolonged along with an increase in the amplitude of the P wave. We report a case of a patient with hypokalemia (1.31 mmol/L) who showed typical electrocardiographic characteristics of hypokalemia.
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Affiliation(s)
- Xiqiang Wang
- Arrhythmia Unit, Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Dan Han
- Arrhythmia Unit, Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Guoliang Li
- Arrhythmia Unit, Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
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44
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Skogestad J, Aronsen JM. Hypokalemia-Induced Arrhythmias and Heart Failure: New Insights and Implications for Therapy. Front Physiol 2018; 9:1500. [PMID: 30464746 PMCID: PMC6234658 DOI: 10.3389/fphys.2018.01500] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/05/2018] [Indexed: 12/18/2022] Open
Abstract
Routine use of diuretics and neurohumoral activation make hypokalemia (serum K+ < 3. 5 mM) a prevalent electrolyte disorder among heart failure patients, contributing to the increased risk of ventricular arrhythmias and sudden cardiac death in heart failure. Recent experimental studies have suggested that hypokalemia-induced arrhythmias are initiated by the reduced activity of the Na+/K+-ATPase (NKA), subsequently leading to Ca2+ overload, Ca2+/Calmodulin-dependent kinase II (CaMKII) activation, and development of afterdepolarizations. In this article, we review the current mechanistic evidence of hypokalemia-induced triggered arrhythmias and discuss how molecular changes in heart failure might lower the threshold for these arrhythmias. Finally, we discuss how recent insights into hypokalemia-induced arrhythmias could have potential implications for future antiarrhythmic treatment strategies.
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Affiliation(s)
- Jonas Skogestad
- Division of Cardiovascular and Pulmonary Diseases, Institute of Experimental Medical Research, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Jan Magnus Aronsen
- Department of Pharmacology, Faculty of Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway.,Bjørknes College, Oslo, Norway
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45
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Abnormal serum potassium levels and 6-month all-cause mortality in patients co-treated with antipsychotic and diuretic drugs - A Danish register-based cohort study. Eur Neuropsychopharmacol 2018; 28:1006-1014. [PMID: 30017260 DOI: 10.1016/j.euroneuro.2018.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 05/25/2018] [Accepted: 06/25/2018] [Indexed: 12/22/2022]
Abstract
Psychiatric patients have excess mortality compared to the general population, and several potential mechanisms may explain this increased risk. This study examined the relationship between serum potassium levels and risk of all-cause mortality in patients co-treated with antipsychotic and diuretic drugs. Using a register-based cohort design, we identified patients between 1995 and 2012 who received a combination of an antipsychotic and a diuretic drug and who further had a serum potassium measurement within 90 days. During the study period, we included the most frequently redeemed antipsychotic drugs with regard to the propensity of corrected QT (QTc) prolongation: zuclopenthixol (unknown/mild), flupentixol (mild), levomepromazine (moderate), and quetiapine (moderate/severe). Patients co-treated with antidepressant drugs, lithium, and other antipsychotic drugs were excluded. Outcome was 6-month all-cause mortality, estimated with multivariable Cox regression. Patients were divided into seven serum potassium levels using restricted cubic splines (reference: 4.2-4.4 mmol/L) and stratified according to the included antipsychotic drugs. Of 6729 patients (median age: 74.0 years; women: 65.3%), 10.8% had hypokalemia and 4.9% had hyperkalemia. Hyperkalemia (>5.0 mmol/L, HR 2.82 [95% CI 2.25-3.54]), hypokalemia (<3.5 mmol/L, HR 1.59 [95% CI 1.29-1.95]), and high normal potassium levels (4.5-4.7 mmol/L, HR 1.44 [95% CI 1.19-1.75]; 4.8-5.0 mmol/L, HR 1.60 [95% CI 1.26-2.04]) were associated with an increased risk of 6-month all-cause mortality. This risk was independent of antipsychotic drugs (interaction: P = 0.06). Our findings imply that excess mortality in patients co-treated with antipsychotic and diuretic drugs is related to serum potassium levels and independent of antipsychotic drugs.
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46
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Affiliation(s)
- C E Chua
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - E Choi
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - E Y H Khoo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, and Division of Endocrinology, University Medicine Cluster, National University Health System, Singapore
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47
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Lip GYH, Coca A, Kahan T, Boriani G, Manolis AS, Olsen MH, Oto A, Potpara TS, Steffel J, Marín F, de Oliveira Figueiredo MJ, de Simone G, Tzou WS, Chiang CE, Williams B, Dan GA, Gorenek B, Fauchier L, Savelieva I, Hatala R, van Gelder I, Brguljan-Hitij J, Erdine S, Lovic D, Kim YH, Salinas-Arce J, Field M. Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2018; 19:891-911. [PMID: 28881872 DOI: 10.1093/europace/eux091] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 03/11/2017] [Indexed: 12/23/2022] Open
Abstract
Hypertension is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease, stroke, peripheral artery disease and chronic renal insufficiency. Hypertensive heart disease can manifest as many cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in hypertensive patients, especially in those with left ventricular hypertrophy (LVH) or HF. Also, some of the antihypertensive drugs commonly used to reduce blood pressure, such as thiazide diuretics, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesemia), further contributing to arrhythmias, whereas effective control of blood pressure may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between hypertension and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit to comprehensively review the available evidence to publish a joint consensus document on hypertension and cardiac arrhythmias, and to provide up-to-date consensus recommendations for use in clinical practice. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient.
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Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Antonio Coca
- Hypertension and Vascular Risk Unit, Department of Internal Medicine, Hospital Clínic (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Thomas Kahan
- Karolinska Institutet Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.,Department of Cardiology, Danderyd University Hospital Corp, Stockholm, Sweden
| | - Giuseppe Boriani
- Cardiology Department, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital and Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, University of Southern Denmark, Denmark
| | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Heart and Health Foundation of Turkey, Ankara, Turkey
| | - Tatjana S Potpara
- School of Medicine, Cardiology Clinic, Clinical Centre of Serbia, Belgrade University, Belgrade, Serbia
| | - Jan Steffel
- Electrophysiology and Cardiac Devices, Department of Cardiology, University Heart Center Zurich; Zurich, Switzerland
| | - Francisco Marín
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Murcia, Spain
| | | | - Giovanni de Simone
- Department of Translational Medical Sciences, Federico II University Hospital, via S. Pansini 5, bld # 1, Napoli 80131, Italy
| | - Wendy S Tzou
- Cardiac Electrophysiology, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Chern-En Chiang
- Division of Cardiology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Bryan Williams
- Institute of Cardiovascular Science, University College London, UK
| | | | - Gheorghe-Andrei Dan
- Colentina University Hospital, Medicine Faculty, University of Medicine "Carol Davila"-Bucharest Romania
| | | | | | | | - Robert Hatala
- National Cardiovascular Institute, NUSCH, Bratislava, Slovak Republic
| | - Isabelle van Gelder
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jana Brguljan-Hitij
- University Medical Centre, Hypertension Department, Hospital Dr. Peter Drzaja, Ljubljana, Slovenia
| | - Serap Erdine
- Istanbul University Cerrahpasa Medical School, Head of Hypertension Department, Istanbul, Turkey
| | - Dragan Lovic
- Clinic for internal disease Intermedica, Cardiology department-Hypertension centere, Serbia
| | | | | | - Michael Field
- University of Wisconsin, Clinical Science Center, Madison, USA
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Kaya A, Keskin M, Tatlisu MA, Kayapinar O. Effect of Dynamic Potassium Change on In-Hospital Mortality, Ventricular Arrhythmias, and Long-Term Mortality in STEMI. Angiology 2018; 70:69-77. [PMID: 29962233 DOI: 10.1177/0003319718784127] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We evaluated the effect of serum potassium (K) deviation on in-hospital and long-term clinical outcomes in patients with ST-segment elevation myocardial infarction who were normokalemic at admission. A total of 2773 patients with an admission serum K level of 3.5 to 4.5 mEq/L were retrospectively analyzed. The patients were categorized into 3 groups according to their K deviation: normokalemia-to-hypokalemia, normokalemia-to-normokalemia, and normokalemia-to-hyperkalemia. In-hospital mortality, long-term mortality, and ventricular arrhythmias rates were compared among the groups. In a hierarchical multivariable regression analysis, the in-hospital mortality risk was higher in normokalemia-to-hypokalemia (odds ratio [OR] 3.03; 95% confidence interval [CI], 1.72-6.82) and normokalemia-to-hyperkalemia groups (OR 2.81; 95% CI, 1.93-4.48) compared with the normokalemia-to-normokalemia group. In a Cox regression analysis, long-term mortality risk was also higher in normokalemia-to-hypokalemia (hazard ratio [HR] 3.78; 95% CI, 2.07-7.17) and normokalemia-to-hyperkalemia groups (HR, 2.97; 95% CI, 2.10-4.19) compared with the normokalemia-to-normokalemia group. Ventricular arrhythmia risk was also higher in normokalemia-to-hypokalemia group (OR 2.98; 95% CI, 1.41-5.75) compared with normokalemia-to-normokalemia group. The current study showed an increased in-hospital ventricular arrhythmia and mortality and long-term mortality rates with the deviation of serum K levels from normal ranges.
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Affiliation(s)
- Adnan Kaya
- 1 Cardiology, Duzce University School of Medicine, Konuralp, Duzce, Turkey
| | - Muhammed Keskin
- 2 Cardiology, Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | | | - Osman Kayapinar
- 1 Cardiology, Duzce University School of Medicine, Konuralp, Duzce, Turkey
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49
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Colombo MG, Kirchberger I, Amann U, Dinser L, Meisinger C. Association of serum potassium concentration with mortality and ventricular arrhythmias in patients with acute myocardial infarction: A systematic review and meta-analysis. Eur J Prev Cardiol 2018; 25:576-595. [DOI: 10.1177/2047487318759694] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Challenging clinical practice guidelines that recommend serum potassium concentration between 4.0–5.0 mEq/L or ≥4.5 mEq/L in patients with acute myocardial infarction, recent studies found increased mortality risks in patients with a serum potassium concentration of ≥4.5 mEq/L. Studies investigating consequences of hypokalemia after acute myocardial infarction revealed conflicting results. Therefore, the aim of this systematic review and meta-analysis was to combine evidence from previous studies on the association of serum potassium concentration with both short and long-term mortality as well as the occurrence of ventricular arrhythmias. Design Systematic review and meta-analysis. Methods A structured search of MEDLINE and EMBASE databases yielded 23 articles published between 1990 and January 2017 that met the inclusion criteria. Study selection, data extraction and quality assessment were carried out by three reviewers. Random effects models were used to pool estimates across the included studies and sensitivity analyses were performed when possible. Results Twelve studies were included in the meta-analysis. Both pooled results from six studies investigating short-term mortality and from five studies examining long-term mortality revealed significantly increased risks in patients with serum potassium concentrations of <3.5 mEq/L, 4.5–<5.0 mEq/L and ≥5.0 mEq/L after acute myocardial infarction. In addition, a serum potassium concentration of <3.5 mEq/L was significantly associated with the occurrence of ventricular arrhythmias. Conclusions Mortality, both short and long term, and the occurrence of ventricular arrhythmias in patients with acute myocardial infarction seem to be negatively associated with hypokalemic serum potassium concentration. There is evidence for adverse consequences of serum potassium concentrations of ≥4.5 mEq/L. Due to the heterogeneity among existing studies, further research is necessary to confirm the need to change clinical practice guidelines.
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Affiliation(s)
- Miriam Giovanna Colombo
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
| | - Inge Kirchberger
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
- Chair of Epidemiology, UNIKA-T, Ludwig-Maximilians-Universität München, Germany
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERcv), Spain
| | - Ute Amann
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
- Chair of Epidemiology, UNIKA-T, Ludwig-Maximilians-Universität München, Germany
| | - Lisa Dinser
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
| | - Christa Meisinger
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
- Chair of Epidemiology, UNIKA-T, Ludwig-Maximilians-Universität München, Germany
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50
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Amirnovin R, Lieu P, Imperial-Perez F, Taketomo C, Markovitz BP, Moromisato DY. Safety, Efficacy, and Timeliness of Intravenous Potassium Chloride Replacement Protocols in a Pediatric Cardiothoracic Intensive Care Unit. J Intensive Care Med 2018; 35:371-377. [PMID: 29357785 DOI: 10.1177/0885066617752659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Hypokalemia in children following cardiac surgery occurs frequently, placing them at risk of life-threatening arrhythmias. However, renal insufficiency after cardiopulmonary bypass warrants careful administration of potassium (K+). Two different nurse-driven protocols (high dose and tiered dosing) were implemented to identify an optimal K+ replacement regimen, compared to an historical low-dose protocol. Our objective was to evaluate the safety, efficacy, and timeliness of these protocols. DESIGN A retrospective cohort review of pediatric patients placed on intravenous K+ replacement protocols over 1 year was used to determine efficacy and safety of the protocols. A prospective single-blinded review of K+ repletion was used to determine timeliness. PATIENTS Pediatric patients with congenital or acquired cardiac disease. SETTING Twenty-four-bed cardiothoracic intensive care unit in a tertiary children's hospital. INTERVENTIONS Efficacy was defined as fewer supplemental potassium chloride (KCl) doses, as well as a higher protocol to total doses ratio per patient. Safety was defined as a lower percentage of serum K+ levels ≥4.8 mEq/L after a dose of KCl. Between-group differences were assessed by nonparametric univariate analysis. RESULTS There were 138 patients with a median age of 3.0 (interquartile range: 0.23-10.0) months. The incidence of K+ levels ≥4.8 mEq/L after a protocol dose was higher in the high-dose protocol versus the tiered-dosing protocol but not different between the low-dose and tiered-dosing protocols (high dose = 2.2% vs tiered dosing = 0.5%, P = .05). The ratio of protocol doses to total doses per patient was lower in the low-dose protocol compared to the tiered-dosing protocol (P < .05). Protocol doses were administered 45 minutes faster (P < .001). CONCLUSION The tiered-dosed, nurse-driven K+ replacement protocol was associated with decreased supplemental K+ doses without increased risk of hyperkalemia, administering doses faster than individually ordered doses; the protocol was effective, safe, and timely in the treatment of hypokalemia in pediatric patients after cardiac surgery.
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Affiliation(s)
- Rambod Amirnovin
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Cardiothoracic Intensive Care Unit, Heart Institute, Los Angeles, CA, USA
| | - Phuong Lieu
- Pharmacy Department, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Carol Taketomo
- Pharmacy Department, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Barry P Markovitz
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Cardiothoracic Intensive Care Unit, Heart Institute, Los Angeles, CA, USA
| | - David Y Moromisato
- Department of Pediatrics, Cardon Children's Medical Center, Mesa, AZ, USA
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