Arrhythmias and laboratory abnormalities after an electrical accident: a single-center, retrospective study of 333 cases

BACKGROUND

Even though electrical injuries are common in the emergency room, guidelines, consensus, and general recommendations for the management of these patients do not exist in Europe. Documented cases of delayed arrhythmias are rare and their connection with electrical injury has not been fully confirmed. We also use cardio-specific markers for the risk stratification of myocardial injury, but there is no significant study referring to their utility in this clinical situation. These reasons led us to retrospectively analyze all cases of electrical injuries over 23 years to determine the prevalence of cardiac arrhythmias (mainly malignant arrhythmias and delayed arrhythmias).

METHODS

We retrospectively searched all patients admitted to the University Hospital in Pilsen, CZ, with a diagnosis of electric injury (ICD diagnostic code T754) from 1997 to 2020. The hospital´s information system was used to research the injury; data were drawn from patient medical records.

RESULTS

We identified 333 cases of electrical injury in our hospital. Men accounted for about two-thirds, and women one-third. Children accounted for about one-third of cases. Most were low-voltage injuries (< 1000 V, 91.6%). All participants had an initial ECG, and 77.5% of patients had continuous ECG monitoring, usually lasting 24 h. Cardiac arrhythmias were noticed in 39 patients (11.7%). The most frequent arrhythmias were: ventricular fibrillation, sinus tachycardia, bradycardia and arrhythmia, atrial fibrillation, and supraventricular tachycardia. The ECG showed cardiac conduction abnormalities in 28 patients (8.1%), and ten patients (3%) had supraventricular or ventricular extrasystoles. In ten cases (3%), we found changes in ST segments and T waves on the initial ECG. Thirty-one patients (9.3%) suffered a loss of consciousness and 50 patients (15.02%) reported paresthesia. The most frequent ion disbalances were hypokalemia (18%) and hypocalcemia (3.3%). Patients with an ion disbalance had significantly more arrhythmias and newly diagnosed cardiac conduction abnormalities. Troponin levels (cTnI or hs-cTnT) were measured in 258 cases (77.48%) and found to be elevated above the 99th percentile in 19 cases (5.7%). Almost one-third of patients had burns of various degrees of seriousness, and 41 patients (12.3%) had concomitant traumatic injuries. Eleven patients underwent pre-hospital resuscitation, three died in the hospital, and another died as result of intracranial hemorrhage.

CONCLUSION

All malignant arrhythmias occurred immediately after the electrical injury, delayed life-threatening arrhythmias were not observed, and no predictive factors of malignant arrhythmias were found. While elevations of cardiac troponins were observed sporadically, they did not appear helpful for risk stratification. In patients with arrhythmias, ion disbalance may be more critical. We concluded that asymptomatic, uninjured adult and pediatric patients with normal initial ECG findings do not need continuous ECG monitoring and may be discharged home. Recommendations for high-risk patients and patients with mild ECG abnormalities at admission are less obvious.

Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials

BACKGROUND

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in patients with cardiogenic shock despite the lack of evidence from adequately powered randomised clinical trials. Three trials reported so far were underpowered to detect a survival benefit; we therefore conducted an individual patient-based meta-analysis to assess the effect of VA-ECMO on 30-day death rate.

METHODS

Randomised clinical trials comparing early routine use of VA-ECMO versus optimal medical therapy alone in patients presenting with infarct-related cardiogenic shock were identified by searching MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and trial registries until June 12, 2023. Trials were included if at least all-cause death rate 30 days after in-hospital randomisation was reported and trial investigators agreed to collaborate (ie, providing individual patient data). Odds ratios (ORs) as primary outcome measure were pooled using logistic regression models. This study is registered with PROSPERO (CRD42023431258).

FINDINGS

Four trials (n=567 patients; 284 VA-ECMO, 283 control) were identified and included. Overall, there was no significant reduction of 30-day death rate with the early use of VA-ECMO (OR 0·93; 95% CI 0·66-1·29). Complication rates were higher with VA-ECMO for major bleeding (OR 2·44; 95% CI 1·55-3·84) and peripheral ischaemic vascular complications (OR 3·53; 95% CI 1·70-7·34). Prespecified subgroup analyses were consistent and did not show any benefit for VA-ECMO (pinteraction ≥0·079).

INTERPRETATION

VA-ECMO did not reduce 30-day death rate compared with medical therapy alone in patients with infarct-related cardiogenic shock, and an increase in major bleeding and vascular complications was observed. A careful review of the indication for VA-ECMO in this setting is warranted.

FUNDING

Foundation Institut für Herzinfarktforschung.

Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used for circulatory support in patients with cardiogenic shock, although the evidence supporting its use in this context remains insufficient. The ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) aimed to compare immediate implementation of VA-ECMO versus an initially conservative therapy (allowing downstream use of VA-ECMO) in patients with rapidly deteriorating or severe cardiogenic shock.

METHODS

This multicenter, randomized, investigator-initiated, academic clinical trial included patients with either rapidly deteriorating or severe cardiogenic shock. Patients were randomly assigned to immediate VA-ECMO or no immediate VA-ECMO. Other diagnostic and therapeutic procedures were performed as per current standards of care. In the early conservative group, VA-ECMO could be used downstream in case of worsening hemodynamic status. The primary end point was the composite of death from any cause, resuscitated circulatory arrest, and implementation of another mechanical circulatory support device at 30 days.

RESULTS

A total of 122 patients were randomized; after excluding 5 patients because of the absence of informed consent, 117 subjects were included in the analysis, of whom 58 were randomized to immediate VA-ECMO and 59 to no immediate VA-ECMO. The composite primary end point occurred in 37 (63.8%) and 42 (71.2%) patients in the immediate VA-ECMO and the no early VA-ECMO groups, respectively (hazard ratio, 0.72 [95% CI, 0.46-1.12]; P=0.21). VA-ECMO was used in 23 (39%) of no early VA-ECMO patients. The 30-day incidence of resuscitated cardiac arrest (10.3.% versus 13.6%; risk difference, -3.2 [95% CI, -15.0 to 8.5]), all-cause mortality (50.0% versus 47.5%; risk difference, 2.5 [95% CI, -15.6 to 20.7]), serious adverse events (60.3% versus 61.0%; risk difference, -0.7 [95% CI, -18.4 to 17.0]), sepsis, pneumonia, stroke, leg ischemia, and bleeding was not statistically different between the immediate VA-ECMO and the no immediate VA-ECMO groups.

CONCLUSIONS

Immediate implementation of VA-ECMO in patients with rapidly deteriorating or severe cardiogenic shock did not improve clinical outcomes compared with an early conservative strategy that permitted downstream use of VA-ECMO in case of worsening hemodynamic status.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02301819.

Bimodal distribution of QRS complex duration in patients with dilated cardiomyopathy undergoing an ICD implant procedure

Background/Introduction

In patients with heart failure with reduced ejection fraction (HFrEF), QRS duration is of the uttermost importance. Substantial proportion of patients with HFrEF and sufficiently prolonged QRS complex, especially those with left bundle branch block (LBBB), may significantly benefit from cardiac resynchronization therapy.

Purpose

The aim of the study was to analyse the distribution of the QRS durations in patients with HFrEF undergoing ICD implant procedure to better understand the phenomenon of QRS prolongation.

Methods

All patients undergoing the implant procedure in our centre between January 2017 and December 2021 for HFrEF caused by coronary artery disease (CAD) or dilated cardiomyopathy (DCM) were analysed for the inclusion into the study. The exclusion criteria were (1) coincidence of CAD with DCM, (2) upgrade from any other cardiac rhythm management device, (3) unavailability of the ECG recording or ECG recording with insufficient quality before the implant procedure, (4) more than one ventricular premature beat in the recording. The study used automatically measured QRS duration by Mortara EKG machines (299 recordings with ELI350, 98 with ELI380, and 10 with ELI250). Statistical analysis was performed in R software [1] with the function locmodes for the visualisation of probability density and excess mass test [2] for assessing statistical significance, both from the multimode package.

Results

The study included 407 patients. In 113 patients with DCM and 177 patients with CAD, the implantation was based on primary prevention (PP) indications, and 24 and 93 patients with DCM and CAD were implanted for secondary prevention (SP) indications. The distribution of QRS durations in the CAD-PP, as well as CAD-SP was unimodal (p=ns). In the DCM-PP group, the distribution was bimodal (p=0.012), in the DCM-SP group, the trend was non-significantly bimodal (p=0.076). Both DCM groups taken together had clearly bimodal distribution (p=0.002 – probability density curve according to locmodes function in the figure). The values between 139 and 142 ms were not present in this group. Below this border zone, two other patients fulfilled the criteria of LBBB, both with the duration close to the border zone (137 and 138 ms). Above this zone, 8 patients had right bundle branch block, the rest had LBBB.

Conclusions

Bimodal distribution of QRS duration values in patients with DCM supports the idea of sudden change of left bundle conduction rather than slow progression of local changes. In CAD, scars and other local impairments in conduction may hide these changes and no clear border zone can be set. With the well-known differences in the measurements of main ECGmachine manufacturers, criteria for bundle branch block in DCM could be set with high accuracy.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Charles University Research Program “Cooperatio – Cardiovascular Science” and the Ministry of Health of the Czech Republic Conceptual Development of Research Organization

Numerical analysis of transcranial magnetic stimulation application in patients with orofacial pain

In this paper, we monitored the accuracy of non-navigated application of repetitive Transcranial Magnetic Stimulation (rTMS) in 10 patients suffering from orofacial pain by using functional magnetic resonance (fMRI), computer modeling and numerical simulation. Through a unique process, each fMRI scan was used to define a Region of Interest (ROI) where the source of the orofacial pain was located, which was to be stimulated using rTMS. For each patient, MRI scans with a spatial resolution of 0.7 mm were converted into an anatomically accurate head model. The head model including the ROI was then co-registered with a model of the stimulation coil in an electromagnetic field numerical simulator. The accuracy of rTMS application was evaluated based on the calculations of electric field intensity distribution in the ROI. The research has yielded unique insight into ROIs (with average volume 904mm3) in patients with orofacial pain and has also extended further possibilities of human head MRI image semi-automatic segmentation. According to the calculations performed, the average ROI volume that was stimulated by an electric field with an intensity of over 80 V/m was only 4.4%, with the maximum ROI volume being 20.5%. Furthermore, a numerical study of the impact of coil rotation and translation was performed. It demonstrated a) the optimal placement of the stimulation coil can significantly increase the volume of the stimulated ROI up to 60% and b) patients with orofacial pain would need precise coil positioning with a navigation error lower than 10 mm. Due to an acceptable proccessing time of up to 6 hours, described numerical simulation opens up new options for precise rTMS treatment planning. This planning platform together withpatient-specific navigated rTMS, could lead to significant increase of treatment outcomes in patients suffering from orofacial pain.

Myocardial Involvement Detected Using Cardiac Magnetic Resonance Imaging in Patients with Systemic Sclerosis: A Prospective Observational Study

Introduction and objectives: Cardiac involvement in systemic sclerosis (SSc) patients affects mortality. Cardiac magnetic resonance (CMR) is capable of detecting structural changes, including diffuse myocardial fibrosis that may develop over time. Our aim was to evaluate myocardial structure and function changes using CMR in patients with SSc without known cardiac disease during a 5-year follow-up and find possible correlations with selected biomarkers. Methods: A total of 25 patients underwent baseline and follow-up CMR examinations according to a pre-specified protocol. Standard biochemistry, five biomarkers (hsTnI, NT-proBNP, galectin-3, sST2, and GDF-15), and disease-specific functional parameters enabling the classification of disease severity were also measured. Results: After five years, no patient suffered from manifest heart disease. Mean extracellular volume (ECV) and T1 mapping values did not change significantly (p ≥ 0.073). However, individual increases in native T1 time and ECV correlated with increased galectin-3 serum levels (r = 0.56; p = 0.0050, and r = 0.71; p = 0.0001, respectively). The progression of skin involvement assessed using the Rodnan skin score and a decrease in the diffusing capacity of the lungs were associated with increased GDF-15 values (r = 0.63; p = 0.0009, and r = −0.51; p = 0.011, respectively). Conclusions: During the 5-year follow-up, there was no new onset of heart disease observed in patients with SSc. However, in some patients, CMR detected progression of sub-clinical myocardial fibrosis that significantly correlated with elevated galectin-3 levels. GDF-15 values were found to be associated with disease severity progression.

A Prospective Single-Center Study of the Effects of Repetitive Transcranial Magnetic Stimulation at 2-Week Follow-Up in 17 Patients with Chronic Orofacial Pain Diagnosed by Infrared Thermography

Background

Infrared thermography is a diagnostic method used to monitor acute and chronic orofacial pain syndrome. Repetitive transcranial magnetic stimulation (rTMS) is a form of non-invasive brain stimulation. This prospective study from a single center aimed to investigate the effects of rTMS and used infrared thermography as a confirmatory test of orofacial pain.

Material/Methods

We used infrared thermography to examine the incidence of inflammatory changes as orofacial pain triggers. During the analysis of rTMS effects on patients with orofacial pain, we compared the decrease in pain and the thermal difference in the study group (n=17) and in the research group (n=13).

Results

In the control group (n=13), there were no statistically significant changes. Both groups showed a significant decrease in self-reported pain. Numerical pain rating scores were significantly lower after S2 stimulation than after S1/M1 (P=0.0071) or sham (P=0.0187) stimulation. The Brief Pain Inventory scores were also lower 3 to 5 days after S2 stimulation than at the pretreatment baseline (P=0.0127 for the intensity of pain and p=0.0074 for the interference of pain), and after S1/M1 (P=0.001 and P=0.0001) and sham (P=0.0491 and P=0.0359) stimulations.

Conclusions

The findings from this study support the role of infrared thermography for the diagnosis of chronic orofacial pain, and showed that on the first and fifth days of rTMS therapy in the study group there was a significant reduction of the thermography findings when compared with the control group without rTMS therapy.

Uricemia in the acute phase of myocardial infarction and its relation to long-term mortality risk

Aim: Although uric acid has antioxidant effects, hyperuricemia has been established as an indicator of increased cardiovascular mortality in various patient populations. Treatment of asymptomatic hyperuricemia in patients with acute myocardial infarction (MI) is not routinely recommended, and the efficacy of such treatment in terms of cardiovascular risk reduction remains doubtful. Materials & methods: In a prospective cohort study, we followed 5196 patients admitted for a MI between 2006 and 2018. We assessed the relationship between baseline uricemia and the incidence of all-cause death and cardiovascular mortality and the effect of long-term allopurinol treatment. Hyperuricemia was defined as serum uric acid >450 μmol/l in men and >360 μmol/l in women. Results: In the entire cohort, the 1-year all-cause and cardiovascular mortality rates were 8 and 7.4%, and the 5-year rates were 18.3 and 15.3%, respectively. Using a fully adjusted model, hyperuricemia was associated with a 70% increased risk of both all-cause death and cardiovascular mortality at 1 year, and the negative prognostic value of hyperuricemia persisted over the 5-year follow-up (for all-cause death, hazard risk ratio = 1.45 [95% CI: 1.23-1.70] and for cardiovascular mortality, hazard risk ratio = 1.52 [95% CI: 1.28-1.80], respectively). Treatment of asymptomatic hyperuricemia with allopurinol did not affect mortality rates. Conclusion: Hyperuricemia detected in patients during the acute phase of an MI appears to be independently associated with an increased risk of subsequent fatal cardiovascular events. However, hyperuricemia treatment with low-dose allopurinol did not prove beneficial for these patients.

MiR-126-3p and MiR-223-3p as Biomarkers for Prediction of Thrombotic Risk in Patients with Acute Myocardial Infarction and Primary Angioplasty

Aim. This study was designed to evaluate the relationship between microRNAs (miRNAs), miR-126-3p and miR-223-3p, as new biomarkers of platelet activation, and predicting recurrent thrombotic events after acute myocardial infarction (AMI). Methods and Results. The analysis included 598 patients randomized in the PRAGUE-18 study (ticagrelor vs. prasugrel in AMI). The measurements of miRNAs were performed by using a novel miRNA immunoassay method. The association of miRNAs with the occurrence of the ischemic endpoint (EP) (cardiovascular death, nonfatal MI, or stroke) and bleeding were analyzed. The miR-223-3p level was significantly related to an increased risk of occurrence of the ischemic EP within 30 days (odds ratio (OR) = 15.74, 95% confidence interval (CI): 2.07-119.93, p = 0.008) and one year (OR = 3.18, 95% CI: 1.40-7.19, p = 0.006), respectively. The miR-126-3p to miR-223-3p ratio was related to a decreased risk of occurrence of EP within 30 days (OR = 0.14, 95% CI: 0.03-0.61, p = 0.009) and one year (OR = 0.37, 95% CI: 0.17-0.82, p = 0.014), respectively. MiRNAs were identified as independent predictors of EP even after adjustment for confounding clinical predictors. Adding miR-223-3p and miR-126-3p to miR-223-3p ratios as predictors into the model calculating the ischemic risk significantly increased the predictive accuracy for combined ischemic EP within one year more than using only clinical ischemic risk parameters. No associations between miRNAs and bleeding complications were identified. Conclusion. The miR-223-3p and the miR-126-3p are promising independent predictors of thrombotic events and can be used for ischemic risk stratification after AMI.

Neuromodulation in the treatment of postoperative epidural fibrosis: comparison of the extent of epidural fibrosis and the effect of stimulation

The goal was to prove that when a cohort of patients is chosen precisely, dorsal column stimulation provides significant improvement to quality of life. We studied a cohort of 50 patients with the history of failed back surgery syndrome coupled with epidural fibrosis (EF). A percutaneous implantation technique was used in each of the 50 patients. The study group was composed of 20 women and 28 men aged 26-67 years (mean age 49). A prospective observational questionnaire-based study was used. According to the methods, Ross's classification was adjusted to four degrees of scar size for our study objective. Despite this adjustment, it was not possible to statistically evaluate our research, due to very similar results in Groups I, III and IV. Patients without epidural fibrosis were assigned to Group 0, and patients with EF of different ranges were assigned to Group 1. The mean change in visual analogue scale DeltaVAS after our division into Group 0 was 4.82; for Group 1 it was 6.13. Evaluation of EF and DeltaVAS correlation by paired t-test shows a statistically higher effect of spinal cord stimulation (SCS) in the epidural fibrosis group, compared to group 0 without postoperative epidural fibrosis (p=0.008). The extent of epidural fibrosis is an important factor for Failed back surgery syndrome (FBSS). FBSS is the basis for the existence of neuropathic pain after lumbar spinal surgery. There is clear evidence of a correlation between patients with epidural scar formation on MR scan and the effect of dorsal column stimulation.

Effect of tapentadol on experimental model of orofacial pain - a pilot study

Acute orofacial pain is associated with significant disability and has a detrimental impact on quality of life. Although various origins of the pain in trigeminal territory can be identified an odontogenic pathology is the most common cause of acute orofacial pain in patients. Due to complex pathophysiology drugs with multitarget action might provide beneficial effect in pain management. The aim of the present study was to experimentally examine the anti-nociceptive effects of tapentadol, an opioid agonist and a norepinephrine reuptake inhibitor (MOR/NRI), in our animal model of orofacial pain. We tested the effect of tapentadol at gradual doses of 1, 2 and 5 mg/kg during thermal and mechanical stimulation in the trigeminal area of adult rats. We observed that tapentadol exhibits antinociceptive effect at dosages of 2 mg/kg and 5 mg/kg and only in association with mechanical stimulation.

Transcranial Neurostimulation (rTMS, tDCS) in the Treatment of Chronic Orofacial Pain

Although commonly seen in the clinical practice, chronic orofacial pain quite often does not have a clear unambiguous organic origin. It may be difficult to find optimal pharmacotherapy, and in many cases, this pain may become pharmacotherapy resistant. Neuromodulation, particularly with electromagnetic neurostimulation techniques, has been widely used for the treatment of different types of pharmacoresistant pain, and repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) exemplify readily available noninvasive neuromodulation methods. We have used rTMS and tDCS to treat pharmacoresistant chronic orofacial pain. rTMS uses an electromagnetic coil placed over the patient's head to induce electrical current impulses within the brain tissue, thereby modulating brain activity. In tDCS, an electrode placement location(s) must be chosen in accordance with the density and the time course of the current, mainly to prevent undesired pathological changes in the underlying tissue. Transcranial neuromodulation methods provide a nondestructive and reversible approach to treatment of severe and otherwise uncontrollable chronic orofacial pain. These methods may be curative - as a part of so called "reconstructive neurosurgery" stimulation of neural structures may be used as an alternative to surgical destruction of neural pathways.

The Effect of Diabetes on Prognosis Following Myocardial Infarction Treated with Primary Angioplasty and Potent Antiplatelet Therapy

Purpose: To investigate the prognostic significance of diabetes mellitus (DM) in patients with high risk acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (pPCI) in the era of potent antithrombotics. Methods: Data from 1230 ST-segment elevation myocardial infarction (STEMI) patients enrolled in the PRAGUE-18 (prasugrel vs. ticagrelor in pPCI) study were analyzed. Ischemic and bleeding event rates were calculated for patients with and without diabetes. The independent impact of diabetes on outcomes was evaluated after adjustment for outcome predictors. Results: The prevalence of DM was 20% (N = 250). Diabetics were older and more often female. They were more likely to have hypertension, hyperlipoproteinemia, multivessel coronary disease and left main disease, and be obese. The primary net-clinical endpoint (EP) containing death, spontaneous nonfatal MI, stroke, severe bleeding, and revascularization at day 7 occurred in 6.1% of patients with, and in 3.5% of patients without DM (HR 1.8; 95% CI 0.978–3.315; p = 0.055). At one year, the key secondary endpoint defined as cardiovascular death, spontaneous MI, or stroke occurred in 8.8% with, and 5.5% without DM (HR 1.621; 95% CI 0.987–2.661; p = 0.054). In those with DM the risk of total one-year mortality (6.8% vs. 3.9% (HR 1.773; 95% CI 1.001–3.141; p = 0.047)) and the risk of nonfatal reinfarction (4.8% vs. 2.2% (HR 2.177; 95% CI 1.077–4.398; p = 0.026)) were significantly higher compared to in those without DM. There was no risk of major bleeding associated with DM (HR 0.861; 95% CI 0.554–1.339; p = 0.506). In the multivariate analysis, diabetes was independently associated with the one-year risk of reinfarction (HR 2.176; 95% Confidence Interval, 1.055–4.489; p = 0.035). Conclusion: Despite best practices STEMI treatment, diabetes is still associated with significantly worse prognoses, which highlights the importance of further improvements in the management of this high-risk population.

Post-procedural radial artery occlusion and patency detection using duplex ultrasound vs. the reverse Barbeau test

The transradial approach is recommended as a first choice in coronary catheterizations and interventions, for among other reasons, the reduction in the number of local complications. A head-to-head comparison of the reverse Barbeau test (RBT) and duplex ultrasonography (DUSG) for the detection of post-procedural radial artery patency and occlusion has not yet been evaluated. In 500 patients from our same-day discharge program (age 65 ± 9.4 years, 148 women), radial artery patency and occlusion, compression time, haematomas, and other local complications were evaluated. Radial artery patency was confirmed in 495 patients (99.0%), and complete radial artery occlusion (RAO) was detected in 2 (0.4%) patients using both methods. In 3 patients (0.6%), the RBT was negative, while incomplete RAO was detected by DUSG. Superficial haematomas (˃ 5 but ≤10 cm) were found in 27 (5.4%) patients. There were no other local complications. Detection of radial artery patency and occlusion using the RBT and DUSG was comparable. The incidence of RAO in our study was extremely low. Thanks to its simplicity, the RBT has the potential to be used as the first method of detection of radial occlusion after coronary catheterizations.

Prolonged Continuous Theta Burst Stimulation of the Motor Cortex Modulates Cortical Excitability But not Pain Perception

Over the past decade, theta-burst stimulation (TBS) has become a focus of interest in neurostimulatory research. Compared to conventional repetitive transcranial magnetic stimulation (rTMS), TBS produces more robust changes in cortical excitability (CE). There is also some evidence of an analgesic effect of the method. Previously published studies have suggested that different TBS parameters elicit opposite effects of TBS on CE. While intermittent TBS (iTBS) facilitates CE, continuous TBS (cTBS) attenuates it. However, prolonged TBS (pTBS) with twice the number of stimuli produces the opposite effect. In a double-blind, placebo-controlled, cross-over study with healthy subjects (n = 24), we investigated the effects of various pTBS (cTBS, iTBS, and placebo TBS) over the right motor cortex on CE and pain perception. Changes in resting motor thresholds (RMTs) and absolute motor-evoked potential (MEP) amplitudes were assessed before and at two time-points (0–5 min; 40–45 min) after pTBS. Tactile and thermal pain thresholds were measured before and 5 min after application. Compared to the placebo, prolonged cTBS (pcTBS) transiently increased MEP amplitudes, while no significant changes were found after prolonged iTBS. However, the facilitation of CE after pcTBS did not induce a parallel analgesic effect. We confirmed that pcTBS with twice the duration converts the conventional inhibitory effect into a facilitatory one. Despite the short-term boost of CE following pcTBS, a corresponding analgesic effect was not demonstrated. Therefore, the results indicate a more complex regulation of pain, which cannot be explained entirely by the modulation of excitability.

Blood pressure measurement in patients with cardiogenic shock: the effect of norepinephrine

BACKGROUND

Before arterial cannulation for invasive blood pressure monitoring, clinical decision-making depends on non-invasive blood pressure in critically ill patients. Whether non-invasive blood pressure is comparable to invasive measurement is not clearly elucidated. We address this issue as it relates to the use of norepinephrine in patients with cardiogenic shock.

METHODS

We analysed invasive and non-invasive blood pressure in 85 patients admitted to the Coronary-Care Unit for cardiogenic shock. We compared initial blood pressure measurement (just after radial artery cannulation) and blood pressure taken during the first 72 hours after admission. Invasive blood pressure was used as the reference method.

RESULTS

Initial invasive mean and systolic arterial pressures were in a good agreement with oscillometric blood pressure; mean differences were -0.4 ± 8.8 and +6.1 ± 14.4 mmHg with correlation coefficients of 0.76 and 0.74. Doses of norepinephrine were significant negative determinants of invasive/oscillometric blood pressure differences. The invasive/oscillometric mean arterial pressures and SBP differences were +0.1 ± 3.4 and 7.6 ± 1.6 mmHg in patients treated with nothing or a maximum norepinephrine dose of 0.6 µg/kg/min. However, treatment with very high doses of norepinephrine was associated with a steep rise in mean arterial pressures and SBP invasive/oscillometric differences (-9.5 ± 3.3 and -8.5 ± 5.2 mmHg). In a total of 967 sets of blood pressure measurements, invasive/oscillometric differences were relatively stable across blood pressure categories, with the exception of measurements assessed after very high norepinephrine doses.

CONCLUSIONS

Non-invasive BP is a sufficient substitute for invasive measurement in cardiogenic shock patients, with the exception of those receiving very high doses of norepinephrine.

3300MiR-126-3P and MiR-223-3p in Prediction of Thrombotic Risk in Patients with Acute Myocardial Infarction and Primary Angioplasty, The Prague-18 Genetic Sub-study

Background

Balancing the intensity and duration of antiplatelet therapy according to thrombotic risk is a fundamental need in order to optimize therapy effectiveness and safety. Incorporation of new predictors in thrombotic risk stratification is therefore of a crucial importance for antiplatelet therapy net clinical benefit.

Purpose

The present analysis aimed to evaluate the relation of miR-126-3p and miR-223-3p, new markers of platelet activation, in order to facilitate prediction of recurrent thrombotic events after acute myocardial infarction (AMI).

Method

The analysis included 598 patients (age median 62 years, men 77.8%) randomized in the Prague-18 study (ticagrelor vs. prasugrel in AIM treated with primary PCI). During the study follow up, 40.6% of patients switched to clopidogrel. Determination of miR was evaluated 24 hours after admission; miR-126-3p and miR-223-3p were normalized by miR-423-3p and miR-150-5p. Quantitative determination of selected miRNAs was performed with a novel microRNA immunoassay method.

Selected miRNAs were compared with key efficacy endpoints (cardiovascular death, nonfatal MI and stroke), stent thrombosis and all hemorrhagic events, and analysed using univariate and multivariate logistic regressions.

Results

Increased values of miR-223-3p were significantly related to the occurrence of combined ischemic endpoint within 30 days [OR (95% CI) 15.739 (2.066; 119.932) p=0.008] and within one year [3.175 (1.40; 7.186) p=0.006]. Decreased ratio of miR-126-3P/miR-223-3p was significantly related to the occurrence of combined ischemic endpoint within 30 days [0.137 (0.031; 0.609) p=0.009] and one year [0.372 (0.169; 0.819) p=0.014]. MiRNAs were identified as independent predictors even after adjustment for confounding clinical predictors (Study arm, Switch to Clopidogrel, Age, Men, BMI, Smoking, History of Hyperlipidemia, Hypertension, DM, MI, PCI, CABG, Chronic heart failure, Chronic renal failure, Peripheral arterial disease, LBBB, RBBB, TIMI <3 after PCI, Number of diseased vessels >1, Stem disease, Suboptimal of failure of PCI, Time to hospital). Adjusted ORs (95% CI) are 11.828 (1.472; 98.011), p=0.022 and 2.394 (1.021; 5.610), p=0.045 for increased value of miR-223-3p and the occurrence of combined ischemic endpoint within 30 days and one year respectively; 0.151 (0.030; 0.757), p=0.022 and 0.407 (0.179; 0.925), p=0.032 for decreased ratio of miR-126–3P/miR-223-3p and the occurrence of combined ischemic endpoint within 30 days and one year respectively. No association between miRNA and bleeding complications was identified.

Conclusion

The miR-223-3p and miR-126-3p to miR-223-3p ratio are strong independent predictors of thrombotic ischemic events and can be used to stratify patients post AMI.

Electrode movement prevention – an animal model

Electrode migration is the most common complication of spinal cord stimulation (SCS). The problem of longitudinal migration has already been solved, but lateral migration remains the most common current complication. The present article describes new electrodes fixation opportunities for the reduction of lateral migration in SCS. The pig was chosen as an animal model to illustrate a new protocol of electrode fixation for the control of lateral and longitudinal migration. The displacement of the electrode was measured using two different optical methods: the digital image stereo-correlation and the digital image processing methods. Fixation with two anchors has always considerably reduced electrode displacement and when fixation is done with two anchors and a loop then lateral migration is reduced by 62.5 % and longitudinal migration is reduced by 94.1 %. It was shown that the results are significantly different at the α=0.001 significance level. Based on a statistical evaluation it is possible to state that the differences between experimental results obtained for three different protocols of lead fixation are statistically significant and we can recommend the new fixation method for common practice.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Factors influencing the accuracy of non-invasive blood pressure measurements in patients admitted for cardiogenic shock

BACKGROUND

Although invasively measured blood pressure (invBP) is regarded as a "gold standard" in critically ill cardiac patients, the non-invasive BP is still widely used, at least at the initiation of medical care. The erroneous interpretation of BP can lead to clinical errors. We therefore investigated the agreement of both methods with respect to some common clinical situation.

METHODS

We included 85 patients hospitalized for cardiogenic shock. We measured BP every 6 h for the first 72 h of hospitalization, in all patients. Each set of BP measurements included two invasive (invBP), two auscultatory (auscBP), and two oscillometric (oscBP) BP measurements. InvBP was considered as a gold standard. Mean non-invasive arterial pressure (MAP) was calculated as (diastolic pressure + (pulse pressure ÷ 3)). We used Bland-Altman analysis and we calculated concordance correlation coefficients to assess agreement between different BP methods.

RESULTS

We obtained 967 sets of BP measurements. AuscMAP and oscMAP were on average only 0.4 ± 8.2 and 1.8 ± 8.5 mmHg higher than invMAP, respectively. On the other hand, auscSBP and oscSBP were on average - 6.1 ± 11.4 and - 4.1 ± 9.8 mmHg lower than invSBP, respectively. However, the mean differences and variability for systolic and diastolic BP variability were large; the 2 standard deviation differences were ± 24 and 18 mmHg. In hypotension, non-invasive BP tended to be higher than invBP while the opposite was true for high BP values. Clinical conditions associated with hypotension generally worsened the accuracy of non-invasive MAP.

CONCLUSIONS

Mean arterial pressure measured non-invasively appears to be in good agreement with invasive MAP in patients admitted for cardiogenic shock. Several clinical associated with hypotension can affect accuracy of non-invasive measurement. Auscultatory and oscillometric measurements had similar accuracy even in patients with arrhythmia.

Tapentadol in an Experimental Animal Model of Acute Orofacial Pain

OBJECTIVE

Tapentadol exhibits a synergistic dual effect effect (MOR / NRI) -agonist effect on noradrena-line reuptake inhibition (NRI). Tapentadol is effective on pain with neuropathic characteristics, therefore we decided to use it in an experimental model of acute orofacial pain.

METHODS

The Orofacial Stimulation Test, developed by Ugo Basile, measures hypersensitivity to thermal or mechanical stimulation of the trigeminal area. In the experiment, rats had to voluntarily contact a thermal or mechanical stimulator with their unshaved vibrissal pad in order to access a food reward. Twenty adult laboratory rats (average weight 345 grams) were tested. Intraperitoneal tapentadol was used in doses of 1 mg/kg and 2 mg/kg.

RESULTS

The results of the pilot study indicate that intraperitoneal administration of tapentadol (2 mg/kg) increased mechanical anti-nociception in rats.

Thermovision: a new diagnostic method for orofacial pain?

BACKGROUND

Infrared thermography can be used to obtain more complete information about a patient's condition. The method can be used in various medical applications for monitoring acute and chronic orofacial pain syndrome. With this diagnostic method, thermal differences in the examined region are usually compared to the same reference region on the opposite side of the body.

METHODS

Infrared quantitative thermography is a non-invasive method for contactless monitoring of dynamic thermal fields on a surface, or in this case, the human body. This method is based on detection of infrared radiation, which is naturally emitted from the surface of the body. In a pilot project with a patient having orofacial pain, changes before and after repetitive transcranial magnetic brain stimulation treatment were assessed.

RESULTS

First-day measurements found significantly higher maximum, minimum, and average temperatures, before and after therapy, in the area where the patient subjectively reported pain. The fifth and final measurements, before and after therapy, found only a slight elevation of the maximum temperature of the assessed regions, relative to the same regions on the opposite side of the face.

CONCLUSION

During the measurements on the fifth day, a thermal difference greater than 0.4°C was only observed relative to the minimum temperatures associated with the regions of self-reported pain before and after therapy. For validation of the effects, this method will need to be tested using a randomized, double-blind study with a larger number of patients.

Do multiple body modifications alter pain threshold?

In recent years, epidemiological data has shown an increasing number of young people who deliberately self-injure. There have also been parallel increases in the number of people with tattoos and those who voluntarily undergo painful procedures associated with piercing, scarification, and tattooing. People with self-injury behaviors often say that they do not feel the pain. However, there is no information regarding pain perception in those that visit tattoo parlors and piercing studios compared to those who don't. The aim of this study was to compare nociceptive sensitivity in four groups of subjects (n=105, mean age 26 years, 48 women and 57 men) with different motivations to experience pain (i.e., with and without multiple body modifications) in two different situations; (1) in controlled, emotionally neutral conditions, and (2) at a "Hell Party" (HP), an event organized by a piercing and tattoo parlor, with a main event featuring a public demonstration of painful techniques (burn scars, hanging on hooks, etc.). Pain thresholds of the fingers of the hand were measured using a thermal stimulator and mechanical algometer. In HP participants, information about alcohol intake, self-harming behavior, and psychiatric history were used in the analysis as intervening variables. Individuals with body modifications as well as without body modifications had higher thermal pain thresholds at Hell Party, compared to thresholds measured at control neutral conditions. No such differences were found relative to mechanical pain thresholds. Increased pain threshold in all HP participants, irrespectively of body modification, cannot be simply explained by a decrease in the sensory component of pain; instead, we found that the environment significantly influenced the cognitive and affective component of pain.

Brain stimulation methods for pain treatment

Treatment of pain is one of the most important aims of medicine. Over the past several decades, invasive, semi-invasive and non-invasive brain stimulation methods have been tested and implemented for modulation of the pain. In this review, we bring an overview of those methods including stimulation of both deep brain structures utilizing invasive and semi-invasive techniques and the brain cortex stimulated by non-invasive transcranial magnetic and electrical techniques. Another potentially beneficial method that could modulate pain by stimulating the deep brain with interferential transcranial alternating current is discussed as well.

Effect of the DASH-diet and salt Kardisal® on blood pressure in adolescents with prehypertension (Cooperative multicentre interventional study)

BACKGROUND

In a cooperative multi-center interventional study of 60 probands with prehypertension and normal BMIs were followed for 3 months.

DESIGN

The intervention included the DASH diet for 3 months in 30 probands plus sodium limited intake using the low sodium salt Kardisal® (60% NaCl, 40% KCl) (group A) and the DASH diet for 3 months in 30 probands without Kardisal® (group B).

RESULTS

In group A (n=26 probands evaluated) the systolic blood pressure (median) decreased significantly from 138 to 129 mmHg (p<0.001), while the diastolic blood pressure had a statistically non-significant decrease. In group B (n=25 probands evaluated) the SBP decreased significantly from 135 to 132 mmHg (p<0.001), and the DBP decreased significantly from 85 to 69 mmHg (p<0.001).

CONCLUSION

Despite a relatively short period on the DASH diet, the intervention produced a significant decrease in the blood pressure of prehypertensive adolescents. The additional use of a low sodium salt for home cooking was not found to have any advantages over the DASH diet alone.

Possible etiology and treatment of amyotrophic lateral sclerosis

Amyotrophic Lateral Sclerosis (ALS) is one of the most dangerous and least understood diseases with a pathophysiology that is still largely unknown. In this article we try to provide a pathophysiological explanation of the etiological, pathogenetic, and clinical aspects of ALS. After a description of the rather complicated classification of the disease, we continue with an evaluation of its clinical presentation. The bibliography reveals several suspect etiological factors including atherosclerosis, inflammation, tumors, cataracts, diabetes mellitus type 2, aging, and degeneration of the nervous system. One of the more intriguing factors involves changes associated with oxidative damage to both neurons and glial cells. It is known that astrocytes support the development of motor neurons. Oxidative damage is known to lead to the expression of stress sensitive genes, proteins, as well as inflammation of glial cells. Chronic inflammation could be a key factor in ALS since it has been linked to the death of motor neurons. Pathophysiological research has confirmed the influence of certains proteins on the prognosis of ALS. ALS is typically a proteinopathy in which proteins aggregate in motoneurons. Additionally, glutamate excitotoxicity has also been linked to ALS, with mutated superoxide dismutase (SOD1) having been shown to be responsible for familial ALS. As concerns the pathogenesis of ALS, we discussed several phenomenon such as increased levels of specific serum compounds, reduced concentrations of myelin, and changes in 5-hydroxytryptamine that could represent key indicators of the pathogenesis, prognosis, and therapy of ALS. Concerning ALS therapy; treatment with antioxidatives is potentially very important. Exposure to heavy metals is also thought to negatively influence ALS. Evidence also suggests that good nutrition is a very important factor in the treatment of ALS. From a pharmacological perspective, serotonin treatment appears to be a useful therapeutic agent.

The variability of automated QRS duration measurement

Aims

Previous studies have demonstrated substantial variability in manual assessment of QRS complex duration (QRSd). Disagreements in QRSd measurements were also found in several automated algorithms tested on digitized electrocardiogram (ECG) recordings. The aim of our study was to investigate the variability of automated QRSd measurements performed by two commercially available electrocardiographs.

Methods and Results

Two GE MAC 5000 (GE-1 and GE-2) electrocardiographs and two Mortara ELI 350 (Mortara-1 and Mortara-2) electrocardiographs were used in the study. Participants for the study were recruited from patients hospitalized in the department of cardiology of a university hospital. Participants underwent up to four recording sessions within a single day with a different electrocardiograph at each session when two to four immediately successive ECG recordings were undertaken. In 76 patients, 683 ECGs were recorded; the mean QRSd was 109.0 ± 26.1 ms. The QRSd difference ≥10 ms between the first and second intra-session ECG was found in 7, 3, 20, and 14% of ECG pairs for GE-1, GE-2, Mortara-1, and Mortara-2, respectively. No inter-session difference in QRSd was found within both manufacturers. In individual patients, Mortara calculated the mean QRSd to be longer by 7.3 ms (95% CI: 6.2-8.5 ms, P < 0.0001) with a 2.1-times (95% CI: 1.9-2.4) greater standard deviation of the mean QRSd (7.1 vs. 3.3 ms, P < 0.001).

Conclusion

Electrocardiographs from two manufacturers measured QRSd values with a systematic difference and a significantly different level of precision. This may have important clinical implications in selection of suitable candidates for cardiac resynchronization therapy.

[Pathophysiology of pain and its clinical application]

The article describes the pathophysiology of both acute and chronic pain. Some common mechanisms of chronic pain, including somatic and visceral pains, are highlighted. There are also some painful syndromes and their pathophysiological mechanisms with a direct relationship to their treatment. In addition to the basic pharmacotherapeutic options resulting from the pathophysiology of pain, new possibilities of pain therapy are also mentioned, especially the neuromodulatory and neurostimulatory methods again from the point of view of pathophysiological principles. Therapies also include psychotherapy and placebo effect with the point of evidence-based medicine.

Myocardial injury after carbon monoxide intoxication in suicide attempt, with features of both toxic and tako-tsubo cardiomyopathy: case report

Severe carbon monoxide intoxication may cause tissue injury by hypoxemia and histotoxicity. The affection of the heart muscle often leads to transient global or regional systolic dysfunction of left ventricle or both ventricles and increased occurences of malignant arrhytmias. On the contrary, stress-induced cardiomyopathy is described as temporary segmental loss of contractility, mostly in apical segments of the left ventricle with mid- and basal sparing and less common hypokinesias in mid- or basal parts, or affection of both ventricles. This case report is dedicated to a 34-years old male, who was admitted to the department of emergency medicine after suicide attempt by carbon monoxide poisoning. Echocardiography at admission showed akinesias of midsegments of left ventricle and severe hypokinesias of apical and basal segments. Despite severe cardiogenic shock, adequate therapeutic management including mechanical ventilation, normobaric oxygenotherapy and catecholamine treatment led to a complete somatic recovery after 2 weeks, and without any permanent hypoxemic brain injury. Our case might be a coincidence of toxic cardiomyopathy, caused by carbon monoxide poisoning, and takotsubo cardiomyopathy as a result of long term exposition to combined stress factors that may lead even to a suicide attempt. Both types of cardiomyopathies often occure simultaneously due to similar pathophysiologic mechanisms. Both tako-tsubo and toxic cardiomypathy have good prognosis after overcoming the acute phase. Key words: carbon monoxide - cardiogennic shock - cardiomyopathy - suicide - tako-tsubo cardiomypathy.

Coagulation and endothelial dysfunction during longterm hyperdynamic porcine bacteremia – effects of selective inducible nitric oxide synthase inhibition

Coagulation abnormalities have been implicated in the pathogenesis of sepsis and organ dysfunction. Nitric oxide (NO) is regarded as a critical mediator of many vascular pathologies, including sepsis. However, limited evidence is available to document a relationship between NO generated by inducible NO synthase (iNOS) and hemostatic abnormalities in sepsis. Therefore, we evaluated the effects of selective iNOS inhibition on markers of endothelial and coagulation homeostasis in a clinically relevant model of porcine bacteremia induced and maintained for 24 hours (h) with a continuous infusion of live P. aeruginosa. After 12 h of sepsis, animals received either vehicle (Control, n = 7) or continuous infusion of selective iNOS inhibitor L-NIL (n=7). Before as well as 12, 18 and 24 h after starting P. aeruginosafollowing variables related to i) endothelial dysfunction (von Willebrand factor [vWf]; tissue plasminogen activator activity [t-PA]; ii) coagulation (thrombin-antithrombin complexes [TAT]; platelet count); iii) fibrinolysis (t-PA activity, activity of plasminogen activator inhibitor type 1 (PAI-1 act); and iv) oxidative/ nitrosative stress (isoprostanes, nitrate/nitrite levels) were measured. L-NIL inhibited sepsis-induced increase in plasma nitrate/nitrite and isoprostanes concentrations, prevented hypotension and acidosis. L-NIL significantly attenuated sepsisinduced rise in plasma vWF and TAT. P. aeruginosa-induced drop in t-PA activity was blunted by iNOS inhibition, while increased PAI-1 and reduced platelet count were not reversed by the treatment. In conclusion, selective iNOS inhibition was associated with attenuation of sepsis-induced coagulation and endothelial dysfunction suggesting the interplay between mediators of vascular system and hemostatic balance. Reduction of oxidative stress probably contributes to the beneficial effects afforded by iNOS blockade.

Editor's Choice - Acute Cardiovascular Care Association Position Paper on Intensive Cardiovascular Care Units: An update on their definition, structure, organisation and function

Acute cardiovascular care has progressed considerably since the last position paper was published 10 years ago. It is now a well-defined, complex field with demanding multidisciplinary teamworking. The Acute Cardiovascular Care Association has provided this update of the 2005 position paper on acute cardiovascular care organisation, using a multinational working group. The patient population has changed, and intensive cardiovascular care units now manage a large range of conditions from those simply requiring specialised monitoring, to critical cardiovascular diseases with associated multi-organ failure. To describe better intensive cardiovascular care units case mix, acuity of care has been divided into three levels, and then defining intensive cardiovascular care unit functional organisation. For each level of intensive cardiovascular care unit, this document presents the aims of the units, the recommended management structure, the optimal number of staff, the need for specially trained cardiologists and cardiovascular nurses, the desired equipment and architecture, and the interaction with other departments in the hospital and other intensive cardiovascular care units in the region/area. This update emphasises cardiologist training, referring to the recently updated Acute Cardiovascular Care Association core curriculum on acute cardiovascular care. The training of nurses in acute cardiovascular care is additionally addressed. Intensive cardiovascular care unit expertise is not limited to within the unit's geographical boundaries, extending to different specialties and subspecialties of cardiology and other specialties in order to optimally manage the wide scope of acute cardiovascular conditions in frequently highly complex patients. This position paper therefore addresses the need for the inclusion of acute cardiac care and intensive cardiovascular care units within a hospital network, linking university medical centres, large community hospitals, and smaller hospitals with more limited capabilities.

Interventional left atrial appendage closure vs novel anticoagulation agents in patients with atrial fibrillation indicated for long-term anticoagulation (PRAGUE-17 study)

Atrial fibrillation (AF), with a prevalence of 1% to 2%, is the most common cardiac arrhythmia. Without antithrombotic treatment, the annual risk of a cardioembolic event is 5% to 6%. The source of a cardioembolic event is a thrombus, which is usually formed in the left atrial appendage (LAA). Prevention of cardioembolic events involves treatment with anticoagulant drugs: either vitamin K antagonists or, recently, novel oral anticoagulants (NOAC). The other (nonpharmacologic) option for the prevention of a cardioembolic event involves interventional occlusion of the LAA.

OBJECTIVE

To determine whether percutaneous LAA occlusion is noninferior to treatment with NOAC in AF patients indicated for long-term systemic anticoagulation.

STUDY DESIGN

The trial will be a prospective, multicenter, randomized noninferiority trial comparing 2 treatment strategies in moderate to high-risk AF patients (ie, patients with history of significant bleeding, or history of cardiovascular event(s), or a with CHA₂DS₂VASc ≥3 and HAS-BLED score ≥2). Patients will be randomized into a percutaneous LAA occlusion (group A) or a NOAC treatment (group B) in a 1:1 ratio; the randomization was done using Web-based randomization software. A total of 396 study participants (198 patients in each group) will be enrolled in the study. The primary end point will be the occurrence of any of the following events within 24months after randomization: stroke or transient ischemic attack (any type), systemic cardioembolic event, clinically significant bleeding, cardiovascular death, or a significant periprocedural or device-related complications.

CONCLUSION

The PRAGUE-17 trial will determine if LAA occlusion is noninferior to treatment with NOAC in moderate- to high-risk AF patients.

Noninvasive transcranial direct current stimulation (tDCS) for the treatment of orofacial pain

OBJECTIVE

tDCS is a promising method for the treatment of chronic pain. Electrode placement locations must be chosen in accordance with the density and the time course of the current in order to prevent pathological changes in the underlying tissue. In order to reduce current spatial variability, more electrodes of the same polarity are placed in a circle around the second electrode of the opposite polarity. The applied current produced the greatest changes directly beneath the electrodes: the cathode reduces the excitability of cortical neurons, while the anode has the opposite effect.

METHODS

Based on inclusion criteria, 10 patients with chronic orofacial pain, secondary trigeminal neuralgia after oral surgery, were enrolled and underwent both anode and cathode stimulation. Before the first session we measured pain intensity on a numeric pain rating scale and tactile and thermal stimulation were used to assess somatosensory status. tDCS was applied for five consecutive days. At the end of tDCS application, somatosensory status was assessed again.

RESULTS

From our results we can conclude that the application of tDCS improves the perception of some types of pain. When we increase our sample size, we would expect confirmation not only on our positive results, but also some additional findings for explaining the pathophysiology of orofacial pain. These pathophysiological findings and explanations are very important for the application of tDCS in the treatment of orofacial pain and also for other types of neuropathic pain.

[Chronic fatifue syndrome.]

Chronic fatigue syndrome - CFS is a disease that lasts about 6 months in adults and in children three months. Other names are myalgia encephalomyelitis, postviral immune syndrome, chronic fatigue immune dysfunction syndrome. The reasons are biological, genetical, infectious or psychological. The paper discusses the history of chronic fatigue syndrome, epidemiology and its prevalence, clinical course, pathophysiology, diagnosis, therapy and prognosis, and also economics.

Prolonged Corrected QT Interval as a Predictor of Clinical Outcome in Acute Ischemic Stroke

BACKGROUND

This study aimed to investigate changes of corrected QT (QTc) interval during acute ischemic stroke and its correlation with high-sensitivity troponin I (hsTnI), brain natriuretic peptide (BNP), neurological outcome, and 1-year mortality.

METHODS

We registered electrocardiogram in 69 patients immediately after admission to the intensive care unit and then after 24 and 48 hours. Computed tomography was performed on admission to determine brain infarct size and localization. Neurological outcome was assessed by modified Rankin scale (mRS) at discharge.

RESULTS

Forty-five (65.2%) patients had prolonged QTc at baseline; only 18 (26.1%) patients had prolonged QTc after 48 hours. Baseline QTc was not associated with neurological outcome (P = .27). However, prolonged QTc after 48 hours was associated with worse mRS at discharge (4.5 [4.0-6.0] versus 2.0 [1.0-3.0]; P < .0001). Patients who deceased during hospitalization (n = 7 [10.1%]) as compared with survivors had more frequently prolonged QTc after 48 hours (38.9 versus 0%; P < .0001), higher level of hsTnI (48.4 [36.1-75.0] versus 8.6 [3.4-26.5]; P = .003), and BNP (334 [224-866] versus 109 [30-190]; P = .014). In univariate analysis, 1-year mortality was associated with prolonged QTc after 48 hours, hsTnI, and BNP. In multivariate analysis, only BNP remained to be associated with 1-year mortality (odds ratio 3.41, 95% confidence interval 1.06-11.03).

CONCLUSIONS

QTc interval in patients with acute ischemic stroke is a dynamic parameter. Prolonged QTc after 48 hours, but not baseline QTc, correlated with neurological outcome and 1-year mortality. Patients with prolonged QTc had higher level of hsTnI.

Prasugrel Versus Ticagrelor in Patients With Acute Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: Multicenter Randomized PRAGUE-18 Study

BACKGROUND

No randomized head-to-head comparison of the efficacy and safety of ticagrelor and prasugrel has been published in the 7 years since the higher efficacy of these newer P2Y₁₂ inhibitors were first demonstrated relative to clopidogrel.

METHODS

This academic study was designed to compare the efficacy and safety of prasugrel and ticagrelor in acute myocardial infarction treated with primary or immediate percutaneous coronary intervention. A total of 1230 patients were randomly assigned across 14 sites to either prasugrel or ticagrelor, which was initiated before percutaneous coronary intervention. Nearly 4% were in cardiogenic shock, and 5.2% were on mechanical ventilation. The primary end point was defined as death, reinfarction, urgent target vessel revascularization, stroke, or serious bleeding requiring transfusion or prolonging hospitalization at 7 days (to reflect primarily the in-hospital phase). This analysis presents data from the first 30 days (key secondary end point). The total follow-up will be 1 year for all patients and will be completed in 2017.

RESULTS

The study was prematurely terminated for futility. The occurrence of the primary end point did not differ between groups receiving prasugrel and ticagrelor (4.0% and 4.1%, respectively; odds ratio, 0.98; 95% confidence interval, 0.55-1.73; P=0.939). No significant difference was found in any of the components of the primary end point. The occurrence of key secondary end point within 30 days, composed of cardiovascular death, nonfatal myocardial infarction, or stroke, did not show any significant difference between prasugrel and ticagrelor (2.7% and 2.5%, respectively; odds ratio, 1.06; 95% confidence interval, 0.53-2.15; P=0.864).

CONCLUSIONS

This head-to-head comparison of prasugrel and ticagrelor does not support the hypothesis that one is more effective or safer than the other in preventing ischemic and bleeding events in the acute phase of myocardial infarction treated with a primary percutaneous coronary intervention strategy. The observed rates of major outcomes were similar but with broad confidence intervals around the estimates. These interesting observations need to be confirmed in a larger trial.

CLINICAL TRIAL REGISTRATION

URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02808767.

Incidence of severe coronary stenosis in asymptomatic patients with peripheral arterial disease scheduled for major vascular surgery

BACKGROUND

Peripheral arterial disease (PAD) has the risk equivalent of coronary heart disease. The biochemical parameters associated with functionally significant coronary artery stenosis were investigated in asymptomatic patients with PAD who were scheduled for major vascular intervention.

METHODS

A total of 50 PAD patients asymptomatic for coronary heart disease were examined using coronary computed tomography angiography (CTA). A stress myocardial CT perfusion (CTP) test was performed in patients who exhibited coronary stenosis >40%. In patients with stress-induced perfusion defects, the severity of stenosis was assessed using invasive coronary angiography including fractional flow reserve assessment. The CT findings were correlated with both classical and more recently developed parameters of atherosclerosis.

RESULTS

According to the combined CT examination (CTA and stress CT perfusion), 36% of patients exhibited significant coronary stenosis. Stress-induced hypoperfusion was observed in 95.7% of severe stenotic lesions. After adjustment for confounders, the level of high-sensitivity troponin I was associated with severe coronary stenosis (OR 1.260 [95% CI 1.054 to 1.505]). Other biochemical parameters did not correlate with coronary stenosis. The annual mortality rate was 4%.

CONCLUSIONS

The results of the present study confirm a significant diagnostic contribution of a complex cardiac CT examination in patients scheduled for major vascular surgery. A high prevalence of asymptomatic coronary heart disease was observed in this particular patient group. High-sensitivity measurements of troponin I correlated with the extent of the coronary stenosis.

The role of levosimendan in acute heart failure complicating acute coronary syndrome: A review and expert consensus opinion

Acute heart failure and/or cardiogenic shock are frequently triggered by ischemic coronary events. Yet, there is a paucity of randomized data on the management of patients with heart failure complicating acute coronary syndrome, as acute coronary syndrome and cardiogenic shock have frequently been defined as exclusion criteria in trials and registries. As a consequence, guideline recommendations are mostly driven by observational studies, even though these patients have a particularly poor prognosis compared to heart failure patients without signs of coronary artery disease. In acute heart failure, and especially in cardiogenic shock related to ischemic conditions, vasopressors and inotropes are used. However, both pathophysiological considerations and available clinical data suggest that these treatments may have disadvantageous effects. The inodilator levosimendan offers potential benefits due to a range of distinct effects including positive inotropy, restoration of ventriculo-arterial coupling, increases in tissue perfusion, and anti-stunning and anti-inflammatory effects. In clinical trials levosimendan improves symptoms, cardiac function, hemodynamics, and end-organ function. Adverse effects are generally less common than with other inotropic and vasoactive therapies, with the notable exception of hypotension. The decision to use levosimendan, in terms of timing and dosing, is influenced by the presence of pulmonary congestion, and blood pressure measurements. Levosimendan should be preferred over adrenergic inotropes as a first line therapy for all ACS-AHF patients who are under beta-blockade and/or when urinary output is insufficient after diuretics. Levosimendan can be used alone or in combination with other inotropic or vasopressor agents, but requires monitoring due to the risk of hypotension.