1
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Philip M, Hourdain J, Resseguier N, Gouriet F, Casalta JP, Arregle F, Hubert S, Riberi A, Mouret JP, Mardigyan V, Deharo JC, Habib G. Atrioventricular conduction disorders in aortic valve infective endocarditis. Arch Cardiovasc Dis 2024:S1875-2136(24)00052-4. [PMID: 38704289 DOI: 10.1016/j.acvd.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Aortic valve infective endocarditis may be complicated by high-degree atrioventricular block in up to 10-20% of cases. AIM To assess high-degree atrioventricular block occurrence, contributing factors, prognosis and evolution in patients referred for aortic infective endocarditis. METHODS Two hundred and five patients referred for aortic valve infective endocarditis between January 2018 and March 2021 were included in this study. A comprehensive assessment of clinical, electrocardiographic, biological, microbiological and imaging data was conducted, with a follow-up carried out over 1 year. RESULTS High-degree atrioventricular block occurred in 22 (11%) patients. In univariate analysis, high-degree atrioventricular block was associated with first-degree heart block at admission (odds ratio 3.1; P=0.015), periannular complication on echocardiography (odds ratio 6.9; P<0.001) and severe biological inflammatory syndrome, notably C-reactive protein (127 vs 90mg/L; P=0.011). In-hospital mortality (12.7%) was higher in patients with high-degree atrioventricular block (odds ratio 4.0; P=0.011) in univariate analysis. Of the 16 patients implanted with a permanent pacemaker for high-degree atrioventricular block and interrogated, only four (25%) were dependent on the pacing function at 1-year follow-up. CONCLUSIONS High-degree atrioventricular block is associated with high inflammation markers and periannular complications, especially if first-degree heart block is identified at admission. High-degree atrioventricular block is a marker of infectious severity, and tends to raise the in-hospital mortality rate. Systematic assessment of patients admitted for infective endocarditis suspicion, considering these contributing factors, could indicate intensive care unit monitoring or even temporary pacemaker implantation in those at highest risk.
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Affiliation(s)
- Mary Philip
- Cardiology Department, La Timone Hospital, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France.
| | - Jérôme Hourdain
- Cardiology Department, La Timone Hospital, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Noémie Resseguier
- Sciences Économiques & Sociales de la Santé & Traitement de l'Information Médicale (SESSTIM), Aix-Marseille University, Inserm, IRD, 13385 Marseille, France; Biostatistics and Information and Communication Technology Department, La Timone Hospital, AP-HM, 13005 Marseille, France
| | - Frédérique Gouriet
- IHU-Méditerranée Infection, Aix-Marseille University, IRD, AP-HM, MEPHI, 13005 Marseille, France
| | - Jean-Paul Casalta
- IHU-Méditerranée Infection, Aix-Marseille University, IRD, AP-HM, MEPHI, 13005 Marseille, France
| | - Florent Arregle
- Cardiology Department, La Timone Hospital, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Sandrine Hubert
- Cardiology Department, La Timone Hospital, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Alberto Riberi
- Cardiac Surgery Department, La Timone Hospital, AP-HM, 13005 Marseille, France
| | - Jean-Philippe Mouret
- Cardiology Department, La Timone Hospital, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Vartan Mardigyan
- Cardiology Department, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - Jean-Claude Deharo
- Cardiology Department, La Timone Hospital, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Gilbert Habib
- Cardiology Department, La Timone Hospital, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France
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Aldajani A, Bérubé M, Mardigyan V. How and Why to Set Up a Pericardial Disease Clinic. Can J Cardiol 2023; 39:1149-1151. [PMID: 37172644 DOI: 10.1016/j.cjca.2023.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/10/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Affiliation(s)
- Ahmed Aldajani
- Department of Cardiovascular Medicine and Cardiovascular Imaging, McGill University Health Centre, Montréal, Québec, Canada; Department of Internal Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Eastern Province, Saudi Arabia
| | - Marlène Bérubé
- Department of Medicine, Jewish General Hospital, Montréal, Québec, Canada
| | - Vartan Mardigyan
- Department of Medicine, Jewish General Hospital, Montréal, Québec, Canada.
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3
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Aldajani A, Mardigyan V, Chetrit M. A Contemporary Approach to the Diagnosis and Management of Constrictive Pericarditis. Can J Cardiol 2023; 39:1144-1148. [PMID: 37331623 DOI: 10.1016/j.cjca.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 06/20/2023] Open
Affiliation(s)
- Ahmed Aldajani
- Division of Cardiology, McGill University Health Centre, Montréal, Québec, Canada; Department of Internal Medicine, Division of Cardiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia.
| | - Vartan Mardigyan
- Division of Cardiology, Jewish General Hospital, Montréal, Québec, Canada
| | - Michael Chetrit
- Division of Cardiology, McGill University Health Centre, Montréal, Québec, Canada
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4
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Serati L, Mardigyan V, Dominioni CC, Agozzino F, Bizzi E, Trotta L, Nivuori M, Maestroni S, Negro E, Imazio M, Brucato A. Pericardial Diseases in Pregnancy. Can J Cardiol 2023; 39:1067-1077. [PMID: 37086835 DOI: 10.1016/j.cjca.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 04/24/2023] Open
Abstract
Pericardial effusion is the most common manifestation of pericardial diseases during pregnancy. This effusion is benign, mild, or moderate, well tolerated, with spontaneous resolution after delivery; no specific treatment is required. Acute pericarditis is the second most common condition, usually requiring medical therapy during pregnancy. Cardiac tamponade and constrictive pericarditis are rare in pregnancy. Pre-pregnancy counselling is essential in women of childbearing age with recurrent pericarditis to plan pregnancy in a phase of disease quiescence and to review therapy. High-dose aspirin or nonselective nonsteroidal anti-inflammatory drugs, such as ibuprofen and indomethacin, can be used up to the 20th week of gestation. Low-dose prednisone (2.5-10 mg/d) can be administered throughout pregnancy. All of these medications, apart from high-dose aspirin, may be used during lactation. Colchicine is compatible with pregnancy and breastfeeding, and it can be continued throughout pregnancy to prevent recurrences. Appropriate follow-up with a multidisciplinary team with experience in the field is recommended throughout pregnancy to ensure good maternal and fetal outcomes.
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Affiliation(s)
- Lisa Serati
- Department of Internal Medicine, Fatebenefratelli Hospital, Milan, Italy.
| | - Vartan Mardigyan
- Department of Medicine, Jewish General Hospital, Montréal, Québec, Canada
| | | | - Francesco Agozzino
- Department of Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | - Emanuele Bizzi
- Department of Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | - Lucia Trotta
- Department of Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | - Mariangela Nivuori
- Department of Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | - Silvia Maestroni
- Department of Internal Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Enrica Negro
- Department of Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | - Massimo Imazio
- Cardiology, Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, University of Milan, Fatebenefratelli Hospital, Milan, Italy
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5
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Aldajani A, Imazio M, Klein A, Mardigyan V. How to Use Interleukin-1 Antagonists in Patients With Pericarditis. Can J Cardiol 2023; 39:1132-1135. [PMID: 36878284 DOI: 10.1016/j.cjca.2023.02.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023] Open
Affiliation(s)
- Ahmed Aldajani
- Department of Cardiovascular Medicine and Cardiovascular Imaging, McGill University Health Centre, Montreal, Quebec, Canada; Department of Internal Medicine, Division of Cardiology, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Eastern Province, Saudi Arabia
| | - Massimo Imazio
- Cardiology, Cardiothoracic Department, University Hospital Santa Maria della Misericordia, and University of Udine, Udine, Italy
| | - Allan Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vartan Mardigyan
- Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada.
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6
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Imazio M, Mardigyan V, Andreis A, Franchin L, De Biasio M, Collini V. New Developments in the Management of Recurrent Pericarditis. Can J Cardiol 2023; 39:1103-1110. [PMID: 37075863 DOI: 10.1016/j.cjca.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/11/2023] [Accepted: 04/11/2023] [Indexed: 04/21/2023] Open
Abstract
Recurrent pericarditis is a common and troublesome complication that affects 15%-30% of patients with a previous episode of pericarditis. However, the pathogenesis of these recurrences is not well understood, and most cases remain idiopathic. Recent advances in medical therapy, including the use of colchicine and anti-interleukin-1 agents like anakinra and rilonacept, have suggested an autoinflammatory rather than an autoimmune mechanism for recurrences with an inflammatory phenotype. As a result, a more personalized approach to treatment is now recommended. Patients with an inflammatory phenotype (fever and elevated C-reactive protein level) should receive colchicine and anti-interleukin-1 agents as first-line therapy, whereas those without systemic inflammation should receive low to moderate doses of corticosteroids (eg, prednisone 0.2-0.5 mg/kg/d as an initial dose) and consider azathioprine and intravenous human immunoglobulins in the case of corticosteroid failure. Tapering of corticosteroids should be slow after achieving clinical remission. In this article, we review the new developments in the management of recurrent pericarditis.
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Affiliation(s)
- Massimo Imazio
- Cardiology and Cardiothoracic Department, University Hospital Santa Maria della Misericordia, and Department of Medicine, University of Udine, Udine, Italy.
| | - Vartan Mardigyan
- Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada
| | - Alessandro Andreis
- University Cardiology, Cardiovascular Department, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Luca Franchin
- Cardiology and Cardiothoracic Department, University Hospital Santa Maria della Misericordia, and Department of Medicine, University of Udine, Udine, Italy
| | - Marzia De Biasio
- Cardiology and Cardiothoracic Department, University Hospital Santa Maria della Misericordia, and Department of Medicine, University of Udine, Udine, Italy
| | - Valentino Collini
- Cardiology and Cardiothoracic Department, University Hospital Santa Maria della Misericordia, and Department of Medicine, University of Udine, Udine, Italy
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7
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Mardigyan V, Imazio M, Brucato A, Fedak PWM, Klein AL. Unveiling the Spectrum of Pericardial Diseases: Insights, Novelties, and Future Directions. Can J Cardiol 2023; 39:1044-1046. [PMID: 37343717 DOI: 10.1016/j.cjca.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 06/23/2023] Open
Affiliation(s)
- Vartan Mardigyan
- Department of Medicine, Jewish General Hospital, Montréal, Québec, Canada.
| | - Massimo Imazio
- Department of Medicine, University Hospital Santa Maria della Misericordia, and University of Udine, Italy; Department of Medicine, University Hospital Santa Maria della Misericordia, and University of Udine, Italy
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, University of Milan, Fatebenefratelli Hospital, Milan, Italy
| | - Paul W M Fedak
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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8
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Aldajani A, Chetrit M, Mardigyan V. Management of post-pericardiotomy constrictive pericarditis. Eur Heart J Case Rep 2022; 7:ytac437. [PMID: 36727133 PMCID: PMC9883704 DOI: 10.1093/ehjcr/ytac437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 10/25/2022] [Accepted: 11/01/2022] [Indexed: 11/07/2022]
Affiliation(s)
| | - Michael Chetrit
- Division of Cardiology, McGill University Health Centre,
845 Rue Sherbrooke O, Montreal, QC H3H 0G4, Canada
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9
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Bedrouni W, Chetrit M, Al Isma'ili A, Galatas C, Kaitoukov Y, Kovacina B, Mardigyan V. Pericarditis Secondary to an Acupuncture Needle Extracted Via a Transjugular Approach. JACC Case Rep 2021; 3:1836-1841. [PMID: 34917964 PMCID: PMC8642725 DOI: 10.1016/j.jaccas.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/23/2021] [Indexed: 11/25/2022]
Abstract
Acupuncture is generally considered safe; however, cardiac complications can occur. We describe a case of refractory pericarditis requiring transvenous extraction of an acupuncture needle from within the right ventricular cavity. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Wassim Bedrouni
- Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Michael Chetrit
- Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Abdullah Al Isma'ili
- Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Christos Galatas
- Department of Medicine, Cité de la Santé Hospital, Laval, Quebec, Canada
| | - Youri Kaitoukov
- Department of Radiology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Bojan Kovacina
- Department of Radiology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Vartan Mardigyan
- Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada
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10
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Negro E, Trotta L, Pancrazi M, Bizzi E, Brenna M, Mardigyan V, Imazio M, Brucato A. COVID-19 Disease in Patients With Recurrent Pericarditis During Treatment With Anakinra: Comment on the Article by Navarro-Millán et al. Arthritis Rheumatol 2021; 73:1562-1563. [PMID: 33644988 PMCID: PMC8014857 DOI: 10.1002/art.41702] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/05/2021] [Indexed: 11/24/2022]
Affiliation(s)
| | | | | | | | | | - Vartan Mardigyan
- McGill University and Jewish General Hospital, Montreal, Quebec, Canada
| | - Massimo Imazio
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Antonio Brucato
- Università di Milano andFatebenefratelli Hospital, Milan, Italy
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11
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Bendayan M, Mardigyan V, Williamson D, Chen-Tournoux A, Eintracht S, Rudski L, MacNamara E, Blostein M, Afilalo M, Afilalo J. Muscle Mass and Direct Oral Anticoagulant Activity in Older Adults With Atrial Fibrillation. J Am Geriatr Soc 2021; 69:1012-1018. [PMID: 33432589 DOI: 10.1111/jgs.16992] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/13/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) are hydrophilic drugs with plasma levels inversely proportional to lean body mass. Sarcopenic patients with low muscle mass may be at risk for supra-therapeutic DOAC levels and bleeding complications. We therefore sought to examine the influence of lean body mass on DOAC levels in older adults with atrial fibrillation (AF). METHODS A prospective cohort study was conducted with patients 65 years of age or more receiving rivaroxaban or apixaban for AF. Appendicular lean mass (ALM) was measured using a bioimpedance device and a dual X-ray absorptiometry scanner. DOAC levels were measured using a standardized anti-Xa assay 4 hours after (peak) and 1 hour before (trough) ingestion. RESULTS The cohort consisted of 62 patients (47% female, 77.0 ± 6.1 years). The prescribed DOACs were apixaban 2.5 mg (21%), apixaban 5 mg (53%), and rivaroxaban 20 mg (26%). Overall, 16% had supra-therapeutic DOAC levels at trough and 25% at peak. In the multivariable logistic regression model, lower ALM was independently associated with supra-therapeutic DOAC levels at trough (odds ratio per ↓ 1-kg 1.23, 95% confidence interval 1.02 to 1.49) and peak (odds ratio per ↓ 1-kg 1.18, 95% confidence interval 1.02 to 1.37). Addition of ALM to a model consisting of age, total body weight, and renal function resulted in improved discrimination for supra-therapeutic DOAC levels. CONCLUSION Our proof-of-concept study has identified an association between ALM and DOAC levels in older adults with AF. Further research is needed to determine the impact of ALM on bleeding complications and the potential role of ALM-guided dosing for sarcopenic patients.
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Affiliation(s)
- Melissa Bendayan
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada.,Centre for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Vartan Mardigyan
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - David Williamson
- Department of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Annabel Chen-Tournoux
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Shaun Eintracht
- Division of Medical Biochemistry, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Lawrence Rudski
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Elizabeth MacNamara
- Division of Medical Biochemistry, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Mark Blostein
- Division of Hematology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Marc Afilalo
- Department of Emergency Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jonathan Afilalo
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada.,Centre for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada.,Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Levett JY, Raparelli V, Mardigyan V, Eisenberg MJ. Cardiovascular Pathophysiology, Epidemiology, and Treatment Considerations of Coronavirus Disease 2019 (COVID-19): A Review. CJC Open 2021; 3:28-40. [PMID: 33458630 PMCID: PMC7801216 DOI: 10.1016/j.cjco.2020.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/02/2020] [Indexed: 01/08/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is rapidly evolving, with important cardiovascular considerations. The presence of underlying cardiovascular risk factors and established cardiovascular disease (CVD) may affect the severity and clinical management of patients with COVID-19. We conducted a review of the literature to summarize the cardiovascular pathophysiology, risk factors, clinical presentations, and treatment considerations of COVID-19 patients with underlying CVD. Angiotensin-converting enzyme 2 (ACE2) has been identified as a functional receptor for the SARS-CoV-2 virus, and it is associated with the cardiovascular system. Hypertension, diabetes, and CVD are the most common comorbidities in COVID-19 patients, and these factors have been associated with the progression and severity of COVID-19. However, elderly populations, who develop more-severe COVID-19 complications, are naturally exposed to these comorbidities, underscoring the possible confounding of age. Observational data support international cardiovascular societies' recommendations to not discontinue ACE inhibitor/angiotensin-receptor blocker therapy in patients with guideline indications for fear of the increased risk of SARS-CoV-2 infection, severe disease, or death. In addition to the cardiotoxicity of experimental antivirals and potential interactions of experimental therapies with cardiovascular drugs, several strategies for cardiovascular protection have been recommended in COVID-19 patients with underlying CVD. Troponin elevation is associated with increased risk of in-hospital mortality and adverse outcomes in patients with COVID-19. Cardiovascular care teams should have a high index of suspicion for fulminant myocarditis-like presentations being SARS-CoV-2 positive, and remain vigilant for cardiovascular complications in COVID-19 patients.
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Affiliation(s)
- Jeremy Y. Levett
- Center of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital/McGill University, Montreal, Quebec, Canada
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Valeria Raparelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Vartan Mardigyan
- Division of Cardiology, Jewish General Hospital/McGill University, Montreal, Quebec, Canada
| | - Mark J. Eisenberg
- Center of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital/McGill University, Montreal, Quebec, Canada
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Cardiology, Jewish General Hospital/McGill University, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
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Trahan MJ, Bastrash MP, Mardigyan V, Klam S. Management of New-Onset Atrial Fibrillation in Pregnancy: When Should Early Delivery Be Considered? J Obstet Gynaecol Can 2019; 42:1012-1015. [PMID: 31882292 DOI: 10.1016/j.jogc.2019.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The hemodynamic and physiological changes of pregnancy may predispose women to cardiac arrhythmias such as atrial fibrillation (AF). Nevertheless, new-onset AF in pregnancy remains rare, and treatment is challenging. Current recommendations are to treat pregnant women with AF as non-pregnant adults, by using pharmacological or synchronized electrical cardioversion, without mention of gestational age or possibility of delivery. CASE A 23-year-old nulliparous woman developed new-onset symptomatic AF at 362 weeks gestation, but presented to our hospital was delivered at 364 weeks gestation. Beta-blockers were administered for heart rate control. After 48 hours, the decision was made to proceed with delivery rather than cardioversion. The patient's arrhythmia resolved spontaneously postpartum without further treatment. CONCLUSION In pregnant patients near or at term, delivery should be considered in the management of new-onset AF after consultation with cardiology, anaesthesiology, and maternal-fetal medicine.
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Affiliation(s)
- Marie-Julie Trahan
- Department of Obstetrics and Gynecology, McGill University, Montréal, QC.
| | | | | | - Stephanie Klam
- Department of Obstetrics and Gynecology, McGill University, Montréal, QC; Department of Maternal-Fetal Medicine, Jewish General Hospital, Montréal, QC
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14
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Imazio M, Andreis A, De Ferrari GM, Cremer PC, Mardigyan V, Maestroni S, Luis SA, Lopalco G, Emmi G, Lotan D, Marcolongo R, Lazaros G, De Biasio M, Cantarini L, Dagna L, Cercek AC, Pivetta E, Varma B, Berkson L, Tombetti E, Iannone F, Prisco D, Caforio ALP, Vassilopoulos D, Tousoulis D, De Luca G, Giustetto C, Rinaldi M, Oh JK, Klein AL, Brucato A, Adler Y. Anakinra for corticosteroid-dependent and colchicine-resistant pericarditis: The IRAP (International Registry of Anakinra for Pericarditis) study. Eur J Prev Cardiol 2019; 27:956-964. [DOI: 10.1177/2047487319879534] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims Novel therapies are needed for recurrent pericarditis, particularly when corticosteroid dependent and colchicine resistant. Based on limited data, interleukin-1 blockade with anakinra may be beneficial. The aim of this multicentre registry was to evaluate the broader effectiveness and safety of anakinra in a ‘real world’ population. Methods and results This registry enrolled consecutive patients with recurrent pericarditis who were corticosteroid dependent and colchicine resistant and treated with anakinra. The primary outcome was the pericarditis recurrence rate after treatment. Secondary outcomes included emergency department visits, hospitalisations, corticosteroid use and adverse events. Among 224 patients (46 ± 14 years old, 63% women, 75% idiopathic), the median duration of disease was 17 months (interquartile range 9–33). Most patients had elevated C-reactive protein (91%) and pericardial effusion (88%). After a median treatment of 6 months (3–12), pericarditis recurrences were reduced six-fold (2.33–0.39 per patient per year), emergency department admissions were reduced 11-fold (1.08–0.10 per patient per year), hospitalisations were reduced seven-fold (0.99–0.13 per patient per year). Corticosteroid use was decreased by anakinra (respectively from 80% to 27%; P < 0.001). No serious adverse events occurred; adverse events consisted mostly of transient skin reactions (38%) at the injection site. Adverse events led to discontinuation in 3%. A full-dose treatment duration of over 3 months followed by a tapering period of over 3 months were the therapeutic schemes associated with a lower risk of recurrence. Conclusion In patients with recurrent pericarditis, anakinra appears efficacious and safe in reducing recurrences, emergency department admissions and hospitalisations.
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Affiliation(s)
- Massimo Imazio
- Coordinating Center: University Cardiology, A.O.U. Città della Salute e della Scienza di Torino, Italy
| | - Alessandro Andreis
- Coordinating Center: University Cardiology, A.O.U. Città della Salute e della Scienza di Torino, Italy
| | - Gaetano Maria De Ferrari
- Coordinating Center: University Cardiology, A.O.U. Città della Salute e della Scienza di Torino, Italy
| | | | | | | | | | - Giuseppe Lopalco
- Department of Emergency and Organ Transplantation (DETO), University of Bari, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Italy
| | - Dor Lotan
- Leviev Heart Center, Chaim Sheba Medical Center (affiliated to Tel Aviv University), Israel
| | - Renzo Marcolongo
- Department of Cardiac Thoracic Vascular Sciences and Public Health, Policlinico Universitario, Italy
| | - George Lazaros
- 1st Cardiology Clinic, Hippokration General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | | | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases, University of Siena, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Italy
| | | | - Emanuele Pivetta
- Emergency Medicine Division and High Dependency Unit and CPO Piemonte, A.O.U. Città della Salute e della Scienza di Torino, Italy
| | - Beni Varma
- Heart and Vascular Institute, Cleveland Clinic, USA
| | | | - Enrico Tombetti
- Dipartimento Scienze Cliniche e biomediche Luigi Sacco, ASST Fatebenefratelli-Sacco, Università degli Studi di Milano, Italy
| | - Florenzo Iannone
- Department of Emergency and Organ Transplantation (DETO), University of Bari, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Firenze, Italy
| | - Alida Linda P Caforio
- Department of Cardiac Thoracic Vascular Sciences and Public Health, Policlinico Universitario, Italy
| | - Dimitrios Vassilopoulos
- 1st Cardiology Clinic, Hippokration General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Dimitrios Tousoulis
- 1st Cardiology Clinic, Hippokration General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Italy
| | - Carla Giustetto
- Coordinating Center: University Cardiology, A.O.U. Città della Salute e della Scienza di Torino, Italy
| | - Mauro Rinaldi
- Coordinating Center: University Cardiology, A.O.U. Città della Salute e della Scienza di Torino, Italy
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, USA
| | | | - Antonio Brucato
- Dipartimento Scienze Cliniche e biomediche Luigi Sacco, ASST Fatebenefratelli-Sacco, Università degli Studi di Milano, Italy
| | - Yehuda Adler
- Leviev Heart Center, Chaim Sheba Medical Center (affiliated to Tel Aviv University), Israel
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Roncero C, Mardigyan V, Service E, Singerman J, Whittaker KC, Friedman M, Chertkow H. Investigation into the effect of transcranial direct current stimulation on cardiac pacemakers. Brain Stimul 2019; 13:89-95. [PMID: 31481297 DOI: 10.1016/j.brs.2019.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/10/2019] [Accepted: 08/16/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Studies investigating the therapeutic applications of transcranial direct current stimulation (tDCS) in the treatment of age-related neurodegenerative disease have been promising. However, exclusion criteria for these studies invariably disqualify patients implanted with internal cardiac pacemakers, citing safety concerns. Because the majority of cardiac pacemaker implantees are over 65, this criterion may limit candidacy for tDCS based research and/or treatment of age-related neurodegenerative disease. OBJECTIVE/HYPOTHESIS We will test the hypothesis that tDCS impacts pacemaker function. Strong electrical potentials, such as those generated by external defibrillators (∼500 V, ∼10 A), are known to occasionally damage pacemaker circuitry and software, but it seems unlikely tDCS would damage a pacemaker because it involves about 1/200th the energy (∼12 V, ∼2 mA) of an external defibrillator. METHODS We delivered tDCS to seven participants (ages 70-92) with bipolar non-dependent pacemakers and subsequently collected data from the internal memory of the pacemakers to assess the tDCS signal detection, as well as alterations in mode switches, impedance levels, and pacing. Subsequently, similar assessments were carried out in participants who were pacemaker-dependent (ages 89-91). RESULTS After a review of the recordings, it was found that tDCS had no impact on the non-dependant, as well as the dependent, pacemakers. There were zero mode switches nor any impact on impedance levels. CONCLUSION Results in this small series of cases found no evidence that tDCS interferes with the function of the pacemakers and suggests tDCS can be delivered to patients equipped with a cardiac pacemaker. Further studies are needed to generalize these results to other pacemakers.
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Affiliation(s)
- Carlos Roncero
- Rotman Research Institute, Baycrest Health Science, Toronto, Canada; Lady Davis Institute, Jewish General Hospital, McGill University, 3755 Chemin de la cote Sainte-Catherine, H3T 1E2, Montreal, Quebec, Canada.
| | - Vartan Mardigyan
- Dept. of Cardiology, Jewish General Hospital, 3755 Chemin de la cote Sainte-Catherine, H3T 1E2, Montreal, Quebec, Canada.
| | - Erik Service
- Lady Davis Institute, Jewish General Hospital, McGill University, 3755 Chemin de la cote Sainte-Catherine, H3T 1E2, Montreal, Quebec, Canada.
| | - Julia Singerman
- Lady Davis Institute, Jewish General Hospital, McGill University, 3755 Chemin de la cote Sainte-Catherine, H3T 1E2, Montreal, Quebec, Canada.
| | - Kayla Chennelle Whittaker
- Lady Davis Institute, Jewish General Hospital, McGill University, 3755 Chemin de la cote Sainte-Catherine, H3T 1E2, Montreal, Quebec, Canada.
| | - Michal Friedman
- Lady Davis Institute, Jewish General Hospital, McGill University, 3755 Chemin de la cote Sainte-Catherine, H3T 1E2, Montreal, Quebec, Canada.
| | - Howard Chertkow
- Rotman Research Institute, Baycrest Health Science, Toronto, Canada; Lady Davis Institute, Jewish General Hospital, McGill University, 3755 Chemin de la cote Sainte-Catherine, H3T 1E2, Montreal, Quebec, Canada.
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Roncero C, Mardigyan V, Chertkow H. Should Cardiac Pace-makers be an exclusion criteria for tDCS? Brain Stimul 2019. [DOI: 10.1016/j.brs.2018.12.921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Chetrit M, Lipes J, Mardigyan V. A Practical Approach to Pericardiocentesis With Periprocedural Use of Ultrasound Training Initiative. Can J Cardiol 2018; 34:1229-1232. [PMID: 30170678 DOI: 10.1016/j.cjca.2018.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 05/23/2018] [Accepted: 06/07/2018] [Indexed: 11/30/2022] Open
Abstract
Tamponade is a life-threatening condition characterized by fluid accumulation in the pericardium, which compresses the cardiac chambers, impairs diastolic filling, and can lead to clinical shock. The diagnosis is a clinical one that is supported by echocardiographic findings. Pericardiocentesis is the definitive treatment for tamponade; however, it remains a challenge for trainees because of the infrequent exposure compared with other invasive procedures. Moreover, this technique, unlike others, can lead to serious complications including cardiac perforation and arrhythmia. There has been increased attention to periprocedural use of ultrasound in various techniques, particularly pericardiocentesis, given its ability to assess the pericardial effusion as well as the safety and feasibility of the procedure from various trajectories to minimize major and minor complications. As such, periprocedural use of ultrasound for pericardiocentesis has emerged as the preferred initial technique for pericardiocentesis. We outline a simple stepwise approach to prepare and perform pericardiocentesis, facilitated by periprocedural ultrasound, including practical tips from our centre's experiences. These include the proper assessment of the target area defined as the most pericardial fluid with the least interfering structures and troubleshooting the introduction of the needle into the pericardium. Absolute contraindications are few and often require surgery, but knowledge of them is mandatory when assessing patients for pericardiocentesis.
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Affiliation(s)
- Michael Chetrit
- Division of Cardiology, Jewish General Hospital, McGill University, Montréal, Québec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada
| | - Jed Lipes
- Division of Cardiology, Jewish General Hospital, McGill University, Montréal, Québec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada; Department of Adult Critical Care, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Vartan Mardigyan
- Division of Cardiology, Jewish General Hospital, McGill University, Montréal, Québec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada.
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Bibas L, Levi M, Touchette J, Mardigyan V, Bernier M, Essebag V, Afilalo J. Implications of Frailty in Elderly Patients With Electrophysiological Conditions. JACC Clin Electrophysiol 2016; 2:288-294. [PMID: 29766886 DOI: 10.1016/j.jacep.2016.04.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/25/2016] [Accepted: 04/27/2016] [Indexed: 01/22/2023]
Abstract
A growing number of complex older adults are referred for electrophysiological conditions and age alone is insufficient to guide management decisions such as implantable cardioverter-defibrillator (ICD) implantation or atrial fibrillation anticoagulation. The concept of frailty has emerged as a geriatric vital sign to gain insight into physiological reserve and prognostic risk beyond chronological age and comorbidities. To date, a number of published studies have evaluated frailty in patients with electrophysiological conditions. These studies collectively demonstrate that frail patients have an increased prevalence of atrial fibrillation, lower use of oral anticoagulation, higher risk of bleeding complications from oral anticoagulation, and higher risk of stroke and mortality. A paucity of studies have explored frailty in the setting of device implantation, with a signal suggesting that frail heart failure patients may have a lower likelihood of being considered for ICD and cardiac resynchronization therapy devices, and a higher risk of fatal and nonfatal events after ICD and cardiac resynchronization therapy implantation. Whether frailty modulates the risks and benefits of these devices is a critical knowledge gap for which further study is clearly warranted.
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Affiliation(s)
- Lior Bibas
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Division of Cardiology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Michael Levi
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Division of Cardiology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Jacynthe Touchette
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Vartan Mardigyan
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Martin Bernier
- Division of Cardiology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Jonathan Afilalo
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.
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Huynh T, Kus T, Greiss I, Breton R, Sarrazin JF, Montigny M, Essebag V, Dion D, Paredes FAA, Sandrin F, Palaic M, Rudski L, Mardigyan V, Garcia MB, Brulotte S, Sami M, Gilles H, Philippon F, O’Hara G, Boudreault C. MULTI-FACETED KNOWLEDGE TRANSLATION TO IMPROVE CARE OF PATIENTS WITH ATRIAL FIBRILLATION: PRELIMINARY RESULTS FROM THE INTEGRATE/FACILITER PROJECTS. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)30804-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Xu Y, Kus T, Greiss I, Montigny M, Sarrazin JF, Dion D, Breton R, Essebag V, Mardigyan V, Rudski L, Garcia MB, Palaic M, Sandrin F, Philippon F, O’Hara G, Huynh T. THE IMPACT OF BODY WEIGHT ON ADVERSE OUTCOMES WITH NOVEL ORAL ANTICOAGULANTS AND WARFARIN: PRELIMINARY RESULTS FROM THE INTEGRATE STUDY. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)30799-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Mardigyan V, Giannetti N, Cecere R, Besner JG, Cantarovich M. Best Single Time Points to Predict the Area-Under-the-Curve in Long-Term Heart Transplant Patients Taking Mycophenolate Mofetil in Combination with Cyclosporine or Tacrolimus. J Heart Lung Transplant 2005; 24:1614-8. [PMID: 16210138 DOI: 10.1016/j.healun.2004.12.112] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2004] [Revised: 11/25/2004] [Accepted: 12/14/2004] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The use of C2 levels for therapeutic drug monitoring (TDM) of cyclosporine microemulsion (CsA) has been clinically validated. Routine TDM of tacrolimus and mycophenolate mofetil (MMF) is based on trough (C0) levels and side effects, respectively. The purpose of the present study was to determine the best single time points to assess the area-under-the-curve (AUC(0-12 hours)) in long-term heart transplant patients being treated with MMF in combination with CsA or tacrolimus. METHODS We studied the AUC(0-12 hours) in long-term (>1 year), adult heart transplant patients being treated with CsA and MMF (14 patients) and with tacrolimus and MMF (9 patients). RESULTS C2 is the best surrogate (r2 = 0.87) of CsA AUC(0-12 hours). Tacrolimus C1 (r2 = 0.78), C2 (r2 = 0.83), C3 (r2 = 0.89) and C4 (r2 = 0.92) correlate better than C0 (r2 = 0.51) with the AUC(0-12 hours). When MMF is combined with CsA, there is poor correlation (r2) of MPA at all measured time points (C0 = 0.49, C2 = 0.09, C3 = 0.23, C4 = 0.44, and C6 = 0.60). When MMF is combined with tacrolimus, MPA C2 (r2 = 0.72), C4 (r2 = 0.86), C6 (r2 = 0.85), and C8 (r2 = 0.93) are better surrogates of the AUC(0-12 hours) compared with C0 (r2 = 0.69). CONCLUSION Our results suggest that in long-term heart transplant patients, the calcineurin inhibitor used in combination with MMF affects the correlation between MPA single time points and the AUC(0-12 hours). Future studies should determine the clinical benefit of TDM of tacrolimus and MPA with C2 or C4 compared with C0 and determine the therapeutic ranges. As for CsA-treated patients, CsA TDM should be performed with C2, and the TDM of MMF may be clinically irrelevant.
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Affiliation(s)
- Vartan Mardigyan
- Department of Medicine, Royal Victoria Hospital, McGill University Health Center, Montréal, Québec, Canada
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Mardigyan V, Tchervenkov J, Metrakos P, Barkun J, Deschenes M, Cantarovich M. Best single time points as surrogates to the tacrolimus and mycophenolic acid area under the curve in adult liver transplant patients beyond 12 months of transplantation. Clin Ther 2005; 27:463-9. [PMID: 15922819 DOI: 10.1016/j.clinthera.2005.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2005] [Indexed: 01/28/2023]
Abstract
BACKGROUND Tacrolimus and mycophenolate mofetil (MMF) are immunosuppressive agents used for the prevention of allograft rejection in liver transplant recipients. Therapeutic drug monitoring (TDM) of tacrolimus is routinely performed using the trough (predose; time 0) plasma drug concentration (C0). In kidney and heart transplant recipients, TDM of MMF has proved to be effective in preventing acute rejection. Some studies have shown that C0 is a poor predictor of drug exposure (represented by AUC), and that concentrations measured after dosing may have a stronger correlation with AUC. However, routine TDM of MMF has not been widely accepted and dose adjustments are usually performed based on adverse effects. OBJECTIVE The aim of the present study was to determine whether plasma drug concentrations measured after dosing would be better correlated with the tacrolimus and mycoplasmic acid (MPA) (the active metabolite of MMF) AUC(0-12) values compared with C0 in liver transplant recipients > or = 12 months after transplantation. METHODS This study was conducted at the Multi-Organ Transplant Program research suite, Royal Victoria Hospital, McGill University Health Center, Montréal, Quebéc, Canada. Liver transplant recipients aged > or = 18 years receiving tacrolimus and MMF > or = 12 months after transplantation were enrolled. The plasma tacrolimus and MPA concentrations were measured before the first morning dose (C0) and at 30 minutes (MPA only) and 1, 2, 3, 4, 6, 8, and 12 hours after the first morning dose (C(30 min), C1, C2, C3, C4, C6, C8, and C12, respectively). RESULTS The study population consisted of 14 patients (7 women, 7 men; mean [SD] age, 57 [16] years; mean [SD] body weight, 75.4 [20.7] kg [range, 44-107 kg]; mean time posttransplant, 42 [30] months). All postdose concentrations (except C(30 min) [MPA]) were better correlated with AUC(0-12) values for tacrolimus and MPA compared with C0. For tacrolimus, the correlations of C0, C2, C3, and C4 with AUC(0-12) were 0.67, 0.83, 0.84, and 0.88, respectively, and for MPA, they were 0.46, 0.73, 0.69, and 0.68, respectively. For tacrolimus, the concentration best correlated with AUC(0-12) was C4. For MPA, the concentration best correlated with AUC(0-12) was C8. CONCLUSION This study in adult liver transplant recipients suggests that for both tacrolimus and MPA, C2, C3, and C4 are better surrogates of AUC(0-12) compared with C0.
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Affiliation(s)
- Vartan Mardigyan
- Department of Medicine, Multi-Organ Transplant Program, Royal Victoria Hospital, McGill University Health Center, Montréal, Quebéc, Canada
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Touyz RM, He G, El Mabrouk M, Diep Q, Mardigyan V, Schiffrin EL. Differential activation of extracellular signal-regulated protein kinase 1/2 and p38 mitogen activated-protein kinase by AT1 receptors in vascular smooth muscle cells from Wistar-Kyoto rats and spontaneously hypertensive rats. J Hypertens 2001; 19:553-9. [PMID: 11327629 DOI: 10.1097/00004872-200103001-00006] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The present study investigates effects of angiotensin II on activation of extracellular signal-regulated protein kinase (ERK) 1/2, p38 mitogen activated-protein kinase (p38MAPK) and c-Jun amino terminal kinase (JNK) in vascular smooth muscle cells from spontaneously hypertensive rats (SHR). METHODS Vascular smooth muscle cells (VSMC) from mesenteric arteries of Wistar-Kyoto (WKY) rats and SHR were studied. Angiotensin II-induced phosphorylation of ERK1/2, JNK and p38MAPK were assessed by Western blot analysis. c-fos mRNA expression by angiotensin II was determined by reverse transcriptase-polymerase chain reaction in the absence and presence of PD98059, selective inhibitor of ERK1/2-dependent pathways and SB202190, selective p38MAPK inhibitor. RESULTS Angiotensin II increased phosphorylation of ERK1/2 and p38MAPK, but not JNK. Responses were significantly increased in SHR compared with WKY. Irbesartan, AT1 receptor antagonist, but not PD123319, AT2 receptor blocker, abolished angiotensin II-induced effects. PP2, selective Src inhibitor, decreased angiotensin II-mediated activation of MAP kinases. Angiotensin II increased c-fos mRNA expression in SHR and had a small stimulatory effect in WKY. These actions were inhibited by PD98059, whereas SB202190 had no effect. CONCLUSIONS Angiotensin II-induced activation of vascular ERK1/2 and p38MAPK is increased in SHR. These effects are mediated via AT1 receptors, which activate Src-dependent pathways. Overexpression of c-fos mRNA in SHR is due to ERK1/2-dependent, p38MAPK-independent pathways. Our results suggest that angiotensin II activates numerous MAP kinases in VSMCs and that differential activation of these kinases may be important in altered growth signaling in VSMCs from SHR.
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MESH Headings
- Angiotensin II/pharmacology
- Animals
- Enzyme Activation/drug effects
- Enzyme Inhibitors/pharmacology
- Flavonoids/pharmacology
- Hypertension/enzymology
- Hypertension/pathology
- Imidazoles/pharmacology
- JNK Mitogen-Activated Protein Kinases
- Male
- Mitogen-Activated Protein Kinase 1/metabolism
- Mitogen-Activated Protein Kinase 3
- Mitogen-Activated Protein Kinases/metabolism
- Muscle, Smooth, Vascular/enzymology
- Muscle, Smooth, Vascular/pathology
- Proto-Oncogene Proteins c-fos/genetics
- Pyridines/pharmacology
- RNA, Messenger/metabolism
- Rats
- Rats, Inbred SHR/metabolism
- Rats, Inbred WKY
- Receptor, Angiotensin, Type 1
- Receptor, Angiotensin, Type 2
- Receptors, Angiotensin/physiology
- Reference Values
- Vasoconstrictor Agents/pharmacology
- p38 Mitogen-Activated Protein Kinases
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Affiliation(s)
- R M Touyz
- Multidisciplinary Research Group on Hypertension, Clinical Research Institute of Montreal, Canada.
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