Ventricular arrhythmias in patients with myocardial infarction and ischaemia. Relationship to serum potassium and magnesium

High-Normal Serum Magnesium and Hypermagnesemia Are Associated With Increased 30-Day In-Hospital Mortality: A Retrospective Cohort Study

Background: Magnesium, the fourth most abundant mineral nutrient in our body, plays a critical role in regulating ion channels and energy generation, intracardiac conduction, and myocardial contraction. In this study, we assessed the association of admission serum magnesium level with all-cause in-hospital mortality in critically ill patients with acute myocardial infarction (AMI).

Methods: Clinical data were extracted from the eICU Collaborative Research Database (eICU-CRD). Only the data for the first intensive care unit (ICU) admission of each patient were used, and baseline data were extracted within 24 h after ICU admission. Logistic regression, Cox regression, and subgroup analyses were conducted to determine the relationship between admission serum magnesium level and 30-day in-hospital mortality in ICU patients with AMI.

Results: A total of 9,005 eligible patients were included. In the logistic regression analysis, serum magnesium at 2.2 to ≤2.4 and >2.4 mg/dl levels were both significant predictors of all-cause in-hospital mortality in AMI patients. Moreover, serum magnesium of 2.2 to ≤2.4 mg/dl showed higher risk of in-hospital mortality than magnesium of >2.4 mg/dl (adjusted odds ratio, 1.63 vs. 1.39). The Cox regression analysis yielded similar results (adjusted hazard ratio, 1.36 vs. 1.25).

Conclusions: High-normal serum magnesium and hypermagnesemia may be useful and easier predictors for 30-day in-hospital mortality in critically ill patients with AMI.

The Hidden Fragility in the Heart of the Athletes: A Review of Genetic Biomarkers

Sudden cardiac death (SCD) is a devastating event which can also affect people in apparent good health, such as young athletes. It is known that intense and continuous exercise along with a genetic background that predisposes a person to the risk of fatal arrhythmias is a trigger for SCD. Therefore, knowledge of the athlete’s genetic conditions underlying the onset of SCD must be extended, in order to develop new effective prevention and/or therapeutic strategies. Arrhythmic features occur across a broad spectrum of cardiac diseases, sometimes presenting with overlapping phenotypes. The genetic basis of arrhythmogenic disorders has been greatly highlighted in the last 30 years, and has shown marked heterogeneity. The advent of next-generation sequencing has constantly updated our understanding of the genetic basis of arrhythmogenic diseases and is laying the foundation for precision medicine. With the exception of a few clinical cases involving a single athlete showing a highly suspected phenotype for the presence of a heart disease, there are few studies to date that analysed the applicability of genetic testing on cohorts of athletes. This evidence shows that genetic testing can contribute to the diagnosis of up to 13% of athletes; however, the presence of clinical markers is essential. This review aims to provide a reference collection on current knowledge of the genetic basis of sudden cardiac death in athletes and to review updated evidence on the effectiveness of genetic testing in early identification of athletes at risk for SCD.

Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies

OBJECTIVES

To determine the quantitative efficacy of different classes of blood pressure lowering drugs in preventing coronary heart disease (CHD) and stroke, and who should receive treatment.

DESIGN

Meta-analysis. Data source Medline (1966-2007).

STUDY SELECTION

Randomised trials of blood pressure lowering drugs recording CHD events and strokes. 108 trials studied differences in blood pressure between study drug and placebo (or control group not receiving the study drug) ("blood pressure difference trials"), and 46 trials compared drugs ("drug comparison trials"). Seven trials with three randomised groups fell into both categories. The results were interpreted in the context of those expected from the largest published meta-analysis of cohort studies, totalling 958 000 people.

PARTICIPANTS

464 000 people defined into three mutually exclusive categories: participants with no history of vascular disease, a history of CHD, or a history of stroke.

RESULTS

In the blood pressure difference trials beta blockers had a special effect over and above that due to blood pressure reduction in preventing recurrent CHD events in people with a history of CHD: risk reduction 29% (95% confidence interval 22% to 34%) compared with 15% (11% to 19%) in trials of other drugs. The extra effect was limited to a few years after myocardial infarction, with a risk reduction of 31% compared with 13% in people with CHD with no recent infarct (P=0.04). In the other blood pressure difference trials (excluding CHD events in trials of beta blockers in people with CHD), there was a 22% reduction in CHD events (17% to 27%) and a 41% (33% to 48%) reduction in stroke for a blood pressure reduction of 10 mm Hg systolic or 5 mm Hg diastolic, similar to the reductions of 25% (CHD) and 36% (stroke) expected for the same difference in blood pressure from the cohort study meta-analysis, indicating that the benefit is explained by blood pressure reduction itself. The five main classes of blood pressure lowering drugs (thiazides, beta blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers) were similarly effective (within a few percentage points) in preventing CHD events and strokes, with the exception that calcium channel blockers had a greater preventive effect on stroke (relative risk 0.92, 95% confidence interval 0.85 to 0.98). The percentage reductions in CHD events and stroke were similar in people with and without cardiovascular disease and regardless of blood pressure before treatment (down to 110 mm Hg systolic and 70 mm Hg diastolic). Combining our results with those from two other studies (the meta-analyses of blood pressure cohort studies and of trials determining the blood pressure lowering effects of drugs according to dose) showed that in people aged 60-69 with a diastolic blood pressure before treatment of 90 mm Hg, three drugs at half standard dose in combination reduced the risk of CHD by an estimated 46% and of stroke by 62%; one drug at standard dose had about half this effect. The present meta-analysis also showed that drugs other than calcium channel blockers (with the exception of non-cardioselective beta blockers) reduced the incidence of heart failure by 24% (19% to 28%) and calcium channel blockers by 19% (6% to 31%).

CONCLUSIONS

With the exception of the extra protective effect of beta blockers given shortly after a myocardial infarction and the minor additional effect of calcium channel blockers in preventing stroke, all the classes of blood pressure lowering drugs have a similar effect in reducing CHD events and stroke for a given reduction in blood pressure so excluding material pleiotropic effects. The proportional reduction in cardiovascular disease events was the same or similar regardless of pretreatment blood pressure and the presence or absence of existing cardiovascular disease. Guidelines on the use of blood pressure lowering drugs can be simplified so that drugs are offered to people with all levels of blood pressure. Our results indicate the importance of lowering blood pressure in everyone over a certain age, rather than measuring it in everyone and treating it in some.

Effect of beer consumption on plasma magnesium: randomized comparison with mineral water

Moderate consumption of ethanol lowers mortality from coronary artery disease, and one of the possible mechanisms is an antiarrhythmic action. We therefore investigated the effect of a small daily dose of beer on plasma electrolytes. 52 men who seldom drank alcohol, clinically stable more than one year after coronary bypass surgery, were randomized to drink either 330 mL beer (containing about 20 g ethanol) or mineral water with similar potassium, magnesium, calcium and sodium content daily for 30 days. Plasma electrolytes and liver function indices, and also heart rate, blood pressure and weight, were measured before and after the trial period. The only significant before-and-after difference was in the group consuming beer, whose plasma magnesium rose from 0.89 (SD 0.01) to 0.98 (SD 0.02) mmol/L (P < 0.0025). This level of beer consumption did no obvious harm to liver function and its possibly beneficial effect on plasma magnesium deserves further investigation.

Changes of ionized magnesium and free fatty acids in serum after acute myocardial infarction

The most feared early complications after an acute myocardial infarction are ventricular arrhythmias. These may be initiated by changed concentrations of catecholamines and electrolytes. The present study shows a reduction of total serum magnesium after acute myocardial infarction which is normalized within a few days. Further, it could be shown that a more significant decrease of ionized Mg2+ (iMg2+) takes place at the day of acute myocardial infarction in the total group of myocardial infarction patients (n = 36). A closer investigation reveals that iMg2+ was considerably decreased in one third of the patients, whereas two thirds showed minor changes of iMg2+ in both directions. The pronounced decrease of iMg2+ in the first sub-group can be explained by the time course of free fatty acids in serum. On the day of the myocardial infarction free fatty acids in serum were increased. This is probably caused by beta-adrenergic-induced lipolysis due to catecholamines released by the stressful situation of an acute myocardial infarction. The increased free fatty acids in serum bind Mg2+, thus reducing iMg2+. As long as a beneficial effect of a general Mg infusion in all acute myocardial infarction patients is controversial, iMg2+ should be measured and Mg infusion therapy should be applied only in patients with low iMg2+.

The scorpion envenoming syndrome

The pathophysiology of the scorpion envenoming syndrome is reviewed with emphasis on the body systems commonly affected. Concepts of the mechanisms underlying venom action, as can be explained by the recently discovered effects on ionic channels, are discussed. The results of clinical analysis of cases of scorpion sting victims and animal experiments with scorpion envenomation supporting these concepts are presented. The pharmacokinetic characteristics of scorpion venoms and their correlation to the magnitude of toxic effects are presented in relation to the potentials of therapeutic intervention. The pharmacological basis of the therapeutic usefulness and toxicities of the drugs commonly used in the treatment of scorpion envenoming is also projected. Finally, the results of a successful nation-wide clinical study with serotherapy of scorpion envenoming are presented and evaluated.

Magnesium homeostasis and clinical disorders of magnesium deficiency

OBJECTIVE

To survey the causes of clinical hypomagnesemia and Mg deficiency. The relationship of hypomagnesemia to digitalis toxicity, congestive heart failure, arrhythmias, and acute myocardial infarction is discussed, as is the clinical interrelationship of Mg and K concentrations, the principal intracellular cations.

DATA SOURCES

A MEDLINE search and retrieval was used to identify relevant references.

STUDY SELECTION

Clinical reports, as well as studies, were selected for this review.

DATA EXTRACTION

There were very few placebo-controlled clinical studies. Clinical observations were related primarily to compilation of series in which Mg was administered and clinical results reported. In addition, conclusions derived from review articles on the subject of clinical Mg depletion were used.

DATA SYNTHESIS

Clinical diagnosis of Mg deficiency is ascertained most expeditiously by estimating serum Mg concentrations. Although available on order by physicians, the lack of routine serum Mg analysis as part of the "electrolyte panel" impedes the diagnosis of clinical Mg deficiency. Renal loss of Mg resulting from the widespread use of loop diuretics is responsible for significant numbers of patients with Mg deficiency and hypomagnesemia. Life-threatening cardiac arrhythmias and seizures represent the most serious manifestations of clinical hypomagnesemia and Mg depletion. In the most critically ill patients, treatment with intravenous Mg is recommended. Oral repletion of Mg is reserved for the less critically ill hospitalized patients and ambulatory patients. Close attention must be paid to optimizing K replenishment in hypokalemic patients by concurrent treatment of any accompanying hypomagnesemia to avoid the problem of refractory K repletion.

CONCLUSIONS

Hypomagnesemia is one of the most frequent serum electrolyte abnormalities in current clinical practice. Routine inclusion of serum Mg analysis in the electrolyte panel will enhance the clinical recognition and treatment of hypomagnesemic Mg-depleted patients. Failure to respond to treatment of recurrent ventricular tachycardia/fibrillation to usual antiarrhythmic therapy in patients with acute myocardial infarction, idiopathic dilated cardiomyopathy, and congestive heart failure should alert the clinician to consider administering intravenous Mg. Repair of coexisting hypomagnesemia in hypokalemic patients is essential to avoid the problem of refractory K repletion caused by coexisting Mg depletion. More controlled clinical studies of Mg deficiency are necessary to ascertain the cost-effectiveness of Mg replacement therapy.

Sudden cardiac death and the potential role of beta-adrenoceptor-blocking drugs

Sudden cardiac death is a major health problem in the industrially developed countries. The risk of sudden cardiac death may be reduced by early detection of coronary heart disease, elimination of the risk factors, treatment of the ischaemia in patients known to have coronary heart disease and suppression of ventricular arrhythmias. Of all the therapeutic measures currently available to reduce the risk of sudden cardiac death, beta-adrenoceptor-blocking drugs (beta blockers) appear to be the most effective. In this paper their actions are reviewed and evidence for their efficacy is presented.

Ventricular arrhythmias late after myocardial infarction are related to hypomagnesemia and magnesium loss: preliminary trial of corrective therapy

It has been well established that in acute myocardial infarction (MI) many patients display low serum magnesium (Mg). This is associated with complex ventricular arrhythmias. The question arises whether predischarge arrhythmias occurring late after MI might also be related to Mg imbalance. In 118 patients subjected to heart rhythm 24 h Holter monitoring in the second or third week after MI, we investigated (1) the relationship between serum Mg, urinary Mg loss, and ventricular arrhythmias, and (2) the effect of Mg supplementation on heart rhythm disturbances. In patients with undisturbed rhythm or monomorphic ventricular ectopic beats (VEB) (Lown 0-2; n = 84), mean serum Mg level (mg% +/- SD) was 1.83 +/- 0.21, whereas in patients with multifocal VEB, pairs, or nonsustained ventricular tachycardia (VT) (Lown 3-4; n = 34) serum Mg was decreased to 1.68 +/- 0.27 (p < 0.01). Serum Mg normal range in our laboratory is 1.7-2.6 mg%. The lowest serum Mg reaching 1.55 +/- 0.27 was found in nonsustained VT (Lown 4 b) subgroup (n = 14). Urinary Mg loss measured in 81 patients was more pronounced in those with Lown 3-4 arrhythmias (n = 26) than with Lown 0-2 (n = 55). The daily values were 73 +/- 22 and 54.4 +/- 26 mg, respectively (p < 0.001). Thirteen patients with complex arrhythmias and low serum Mg received Mg supplementation (MgSO4, 8 g in 500 ml 5% glucose intravenously during 24 h). This resulted in restoration of almost undisturbed rhythm in 10 subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Beneficial effect of magnesium sulfate in acute myocardial infarction

The effects of magnesium on the incidence of arrhythmias and on mortality were evaluated in 103 patients with documented acute myocardial infarction (AMI) in a randomized, double-blind, placebo-controlled study. Fifty patients received a magnesium infusion for 48 hours and 53 received only the vehicle (isotonic glucose) as placebo. The baseline characteristics of the population were similar in the 2 groups. Tachyarrhythmias requiring drug therapy were recorded in 32% of the patients in the magnesium group and in 45% of the placebo group. Conduction disturbances were found in 23% of the placebo group as compared to 14% in the magnesium group. The intrahospital mortality was 2% (1 patient) in the magnesium group, compared to 17% (9 patients) in the placebo group (p less than 0.01). No adverse effects were observed during and after the magnesium infusion. These data support a possible protective role of magnesium in patients with AMI.

Magnesium therapy in ventricular arrhythmias

Magnesium (Mg) is the known activator of 300 enzymes which govern energy utilization, cell permeability, and ionic membrane currents in the cardiac conducting cells. This may explain the antiarrhythmic efficacy of Mg in specific clinical settings, despite its only modest electrophysiological effects. This review summarizes the effect of Mg administration in four clinical conditions: in digitalis toxicity; in drug-induced torsade de pointes; in patients with chronic diuretic therapy; and in acute myocardial infarction. Mg effectively abolished ventricular tachyarrhythmias associated with digitalis intoxication. This effect of Mg is related to the activation of sodium-potassium ATP-ase, which is inhibited by digitalis. Drug-induced torsade de pointes was promptly abolished by Mg sulfate in the clinical setting. Experimental studies showed that Mg suppresses the early afterdepolarizations and the triggered activity responsible for occurrence of the arrhythmia. In diuretic-treated hypertensives, potassium depletion has been associated with increased ventricular ectopy and sudden death. Mg has been found to be an important adjuvant for intracellular repletion of potassium in these patients. Several randomized, double-blind studies in patients with acute infarction showed that Mg administered on admission improved survival or reduced the incidence of complex ventricular arrhythmias. Thus, Mg should be employed as first-line therapy in digitalis intoxication and drug-related torsade de pointes, and should be considered an important adjuvant therapy in hypertensives treated with diuretics and patients with acute myocardial infarction.

Mechanisms underlying the antiarrhythmic properties of beta-adrenoceptor blockade against ischaemia-induced arrhythmias in acutely prepared rats

1. The mechanism underlying the limited antiarrhythmic effects of beta-adrenoceptor blocking agents against occlusion-induced arrhythmias in acutely prepared, pentobarbitone-anaesthetized rats has been investigated. 2. Atenolol, ICI 111,581 and propranolol were given at low, medium and high doses calculated to shift dose-response curves to exogenous agonists by factors of 10-30, 100-300 and 1000-3000, respectively. 3. Arrhythmias, blood pressure, heart rate, ECG changes and serum K+ were measured. 4. Antiarrhythmic activity was seen with beta-blocker treatment. This was minimal with atenolol (0.1, 1 and 10 mg kg-1) and only statistically significant with the highest dose of ICI 111,581 (5 mg kg-1), and propranolol (10 mg kg-1). 5. Treatment with beta-adrenoceptor blockers elevated serum potassium concentrations, as compared with saline controls, especially when measured at 30 min post-occlusion. 6. Only ICI 111,581 (5 mg kg-1) and propranolol (1 and 10 mg kg-1) prolonged P-R interval. 7. In order to evaluate possible mechanisms of antiarrhythmic action, attempts were made to correlate antiarrhythmic activity with beta-blockade, serum potassium concentrations, and/or with changes in the P-R interval of the ECG. 8. Reductions in arrhythmias did not correlate well with presumed beta-blockade. Better correlation was obtained with elevations of serum potassium concentration, and with prolongation of P-R interval (a presumed Class I antiarrhythmic action). 9. These results suggested that antiarrhythmic effects of adrenoceptor blocking agents in acutely-prepared anaesthetized rats, subjected to occlusion of a coronary artery, are unrelated to cardiac beta-blockade. The limited antiarrhythmic effects which were observed could be attributed to elevations in serum potassium concentration (due to peripheral beta-blockade) and/or possible Class I antiarrhythmic actions.

Effects of magnesium on ischemic and reperfusion arrhythmias in the rat heart and electrophysiologic effects of hypermagnesemia in the anesthetized dog

Magnesium sulfate, reportedly clinically effective against some ventricular arrhythmias, has not been extensively studied for its effects on experimental ischemic and reperfusion arrhythmias. We evaluated the effects of three high extracellular concentrations of magnesium (Mg2+) 1.19, 2.38, and 4.76 mM in 70 isolated perfused rat hearts following coronary artery ligation and reperfusion, at each of three different perfusate ionized calcium (Ca2+) concentrations (0.9, 1.25, and, 2.5 mM), where 1.25 mM is close to physiologic. At 0.9 mM Ca2+, higher concentrations of Mg2+ increased the sinus node cycle length (p less than 0.02) and virtually abolished ischemic ventricular tachycardia (VT) and reperfusion ventricular fibrillation (VF) (p less than 0.01), otherwise consistently found in this model. At 1.25 and 2.5 mM Ca2+ increasing Mg2+ had no effect on the incidence of ischemic or reperfusion arrhythmias, although at 1.25 mM Ca2+ ischemic VT had longer cycle lengths and VT appeared after a longer delay (p less than 0.01). In the nonischemic dog heart, marked increases of serum Mg2+ progressively prolonged the A-H, H-V, and QR S intervals, the ventricular effective refractory period, and the sinus cycle length, while the arterial blood pressure fell. Because of its relatively modest electrophysiologic and hemodynamic effects, it is inferred that intravenous magnesium may be given therapeutically with relative safety.

Clinical significance of magnesium: a review

With the increased concern surrounding diuretic-induced electrolyte losses, numerous articles have surfaced investigating the detrimental effects of diuretic-induced hypomagnesemia. This article's purpose is to familiarize the reader with hypomagnesemia and hypermagnesemia. Methods of detection, symptoms, etiologies, and potential modes of therapy are discussed. Particular attention is given to the role magnesium plays in the cardiovascular system with additional discussion on lipid alterations and glucose handling. Specific suggestions are given for the inpatient and outpatient treatment of hypomagnesemia.

Low blood mononuclear cell magnesium in intensive cardiac care unit patients

Magnesium deficiency may play a role in the pathogenesis of atherosclerosis, cardiac arrhythmias, and coronary spasm. Because less than 1% of magnesium (Mg) is extracellular, the serum magnesium (sMg) does not always accurately reflect intracellular Mg stores. To determine the frequency of Mg deficiency in patients with cardiovascular disease, we measured blood mononuclear cell Mg content (mMg) and sMg concentrations in 104 unselected patients admitted to our intensive cardiac care unit (CCU). Twenty-seven normal healthy controls and 33 hypomagnesemic patients with chronic alcoholism and/or malabsorption syndrome served as reference groups. The sMg concentration in the CCU patients was 2.05 +/- 0.03 mg/dl (mean +/- SEM), and did not differ from normal controls (mean 2.01 +/- 0.03 mg/dl). Only 8 of 104 CCU patients were hypomagnesemic (7.7%). mMg in the CCU patients, however, was significantly lower than in the normal controls (1.15 +/- 0.02 micrograms/mg protein and 1.34 +/- 0.02 micrograms/mg protein respectively, p less than 0.001). Fifty-three percent (55 of 104) of CCU patients had mMg contents less than 1.119 micrograms/mg protein, i.e., below that of the lowest normal control. mMg was significantly lower in those patients with congestive heart failure (mMg = 1.08 +/- 0.03 micrograms/mg protein) when compared to those patients without congestive heart failure (1.23 +/- 0.02 micrograms/mg protein, p less than 0.001). We conclude that the incidence of intracellular Mg deficiency in patients with cardiovascular disease is much higher than the sMg would lead one to suspect, and may contribute to clinical cardiovascular morbidity.

The effects of ablations in the central nervous system on arrhythmias induced by coronary occlusion in the rat

The role of the central nervous system (CNS) in arrhythmogenesis in the 4 h period following occlusion of a coronary artery was investigated in rats by use of CNS ablations and other procedures. Ablations in the CNS included pithing, spinalization and decerebration combined with acute and chronic surgical preparation and noradrenaline/adrenaline infusions. All procedures involving acute surgery reduced the incidence and severity of the arrhythmias induced by occlusion. Such reductions were most marked in the second (0.5-4 h post-occlusion) arrhythmic period. The observed reductions in arrhythmias could not be explained in terms of involvement of the CNS or adrenoceptor activation. When circulating leucocytes, platelets and serum potassium were measured in a group of pithed rats before and after occlusion, reduced levels (20-50%) of both leucocytes and platelets occurred while serum potassium levels rose by 50-100%. Arrhythmias following coronary occlusion may depend in part on factors in the blood such as leucocytes, platelets and serum potassium and these factors may be altered by acute surgery.