RESUMEN
OBJECTIVE: To determine the significance of timing of low-density lipoprotein (LDL) cholesterol evaluation in patients with chest pain as it relates to subsequent National Cholesterol Education Program (NCEP) treatment decisions. DESIGN: Prospective, observational study. SETTING: A university-affiliated tertiary care hospital. PATIENTS: Sixty-two patients with coronary heart disease who were not receiving lipid-lowering therapy and whose LDL levels were obtained 25-48 hours after onset of chest pain. INTERVENTION: We evaluated laboratory test results of patients with chest pain admitted to the cardiac care unit to determine risk to patients when LDL levels obtained inappropriately are used to make decisions regarding antihyperlipidemic therapy. MEASUREMENTS AND MAIN RESULTS: Inpatient and outpatient LDL levels were compared, and changes in NCEP treatment decisions analyzed. Differences between inpatient and outpatient LDL levels were significant (p<0.05), which frequently resulted in changes in therapy using the NCEP guidelines. The LDL levels of most inpatients were consistent with NCEP goals for patients with coronary heart disease, whereas the outpatient levels showed a need for drug therapy. CONCLUSION: Lipid values obtained 25-48 hours after hospital admission in patients with acute coronary syndromes do not represent baseline values and may significantly alter the treatment approach; thus, they should not be used to direct drug therapy.
Asunto(s)
LDL-Colesterol/sangre , Enfermedad de la Arteria Coronaria/sangre , Enfermedad Aguda , Adolescente , Anciano , Anciano de 80 o más Años , Errores Diagnósticos , Femenino , Estudios de Seguimiento , Guías como Asunto , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de TiempoRESUMEN
BACKGROUND: Supraventricular tachyarrhythmias are common after open heart surgery. Possible causative factors for these arrhythmias include operative trauma, atrial ischemia, electrolyte imbalances, pericardial irritation, and excess catecholamines. Two agents commonly used to control ventricular rate in atrial fibrillation or atrial flutter (AF/AFL) are beta-blockers and calcium channel blockers. METHODS AND RESULTS: This randomized study was designed to compare the safety and efficacy of intravenous diltiazem versus intravenous esmolol in patients with postoperative AF/AFL after coronary bypass surgery and/or valve replacement surgery. A comparative cost analysis was also performed. Thirty patients received either esmolol (n = 15) or diltiazem (n = 15) for AF/AFL. During the first 6 hours of treatment, 66.6% of esmolol-treated patients converted to sinus rhythm compared with 13.3% of the diltiazem-treated patients (P <.05). At 24 hours, 66.6% of the diltiazem group converted to SR compared with 80% of the esmolol group (not significant). Drug-induced side effects, time to rate control (<90 beats/min), number of patients requiring cardioversion, and length of hospitalization were similar for the two groups. The drug cost/successfully treated patient for esmolol versus diltiazem was $254 versus $437 at 6 hours and $529 versus $262 at 24 hours. CONCLUSIONS: Although this is a small study, it suggests that esmolol is more effective in converting patients to normal sinus rhythm than diltiazem during the initial dosing period. No differences in conversion rates were observed between the two groups after 24 hours. Additional studies are needed to confirm whether esmolol is the initial drug of choice in patients with postoperative AF/AFL after coronary bypass surgery.
Asunto(s)
Fibrilación Atrial/tratamiento farmacológico , Aleteo Atrial/tratamiento farmacológico , Puente de Arteria Coronaria/efectos adversos , Diltiazem/administración & dosificación , Propanolaminas/administración & dosificación , Antagonistas Adrenérgicos beta/uso terapéutico , Adulto , Anciano , Fibrilación Atrial/etiología , Fibrilación Atrial/mortalidad , Aleteo Atrial/etiología , Análisis Costo-Beneficio , Diltiazem/economía , Femenino , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/tratamiento farmacológico , Probabilidad , Pronóstico , Propanolaminas/economía , Valores de Referencia , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
STUDY OBJECTIVE: This study reports a comparison of the time to treatment and cost of administration of alteplase (tPA) and reteplase (rPA) in patients with acute myocardial infarction (MI). DESIGN: Retrospective chart review. SETTING: Hospital emergency department. INTERVENTIONS: A retrospective chart review of 500 MI patients who received alteplase or reteplase was performed. A comparison of time from presentation in the emergency department to start of treatment was performed, and the cost of administration of drugs, including cost of supplies, monitoring time, and IV line complications, was calculated for each drug. RESULTS: The time from presentation to start of treatment was significantly shorter for reteplase than alteplase (51 vs 34 min). This difference resulted from a shorter decision to treat to start of treatment time for reteplase (11 min) compared to alteplase (31 min). The cost of administration of alteplase ranged from $136 to $184 per patient, while the cost of administration of reteplase ranged from $87 to $120 per patient. DISCUSSION: Given the similar safety and efficacy profiles of these thrombolytic agents, the advantages of reteplase in speed of administration and the reduction in cost should be considered when making formulary and drug product selection decisions.). Abbreviated Abstract. Alteplase (tPA) and reteplase (rPA) were compared in a retrospective review of 500 patients. rPA was associated with 17 minute time savings from presentation-to-treatment compared to tPA. rPA was also associated with a per patient cost savings $49 to $64 compared to tPA. The time and cost advantages of rPA should be considered when making drug product selection decisions.
Asunto(s)
Terapia Trombolítica/economía , Terapia Trombolítica/métodos , Anciano , Costos y Análisis de Costo , Femenino , Fibrinolíticos/administración & dosificación , Fibrinolíticos/efectos adversos , Fibrinolíticos/economía , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/tratamiento farmacológico , Infarto del Miocardio/economía , Proteínas Recombinantes/administración & dosificación , Proteínas Recombinantes/efectos adversos , Proteínas Recombinantes/economía , Estudios Retrospectivos , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Tejido Plasminógeno/efectos adversos , Activador de Tejido Plasminógeno/economíaRESUMEN
BACKGROUND: Asymptomatic myocardial ischemia is commonly observed in patients with coronary artery disease. Numerous studies have shown that patients with asymptomatic ischemia are at higher risk for adverse outcome than those without ischemia. Several recent studies have investigated the therapeutic options available in the management of patients with asymptomatic myocardial ischemia. METHODS: Recently published randomized controlled trials investigating the treatment of asymptomatic myocardial ischemia were reviewed. RESULTS: The controlled trials suggest that (1) asymptomatic ischemia can be suppressed to various degrees using pharmacologic therapy or revascularization, (2) beta-blockers are in general superior to calcium channel blockers or nitrates in relieving asymptomatic ischemia, and (3) revascularization is superior to pharmacologic therapy. CONCLUSIONS: A growing body of evidence suggests that in patients with coronary artery disease, treatment of asymptomatic ischemia may result in improved outcome. However, because of significant limitations in the published studies, additional studies with large sample sizes and broader inclusion criteria are needed.
Asunto(s)
Isquemia Miocárdica/terapia , Antagonistas Adrenérgicos beta/uso terapéutico , Bloqueadores de los Canales de Calcio/uso terapéutico , Enfermedad Coronaria/complicaciones , Humanos , Isquemia Miocárdica/tratamiento farmacológico , Isquemia Miocárdica/cirugía , Revascularización Miocárdica , Nitritos/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Resultado del Tratamiento , Vasodilatadores/uso terapéuticoRESUMEN
STUDY OBJECTIVE: To evaluate 24-hour blood pressure control and frequency of adverse effects in patients with mild to moderate hypertension switched from nifedipine gastrointestinal therapeutic system (Nif-GITS) to nifedipine coat core (Nif-CC). DESIGN: Open-label, prospective, switch study SETTING: University-affiliated outpatient cardiology clinic. SUBJECTS: Twenty patients with mild to moderate essential hypertension, who were taking Nif-GITS 30, 60, or 90 mg/day for 8 weeks or longer. INTERVENTIONS: Patients stabilized with Nif-GITS 30, 60, or 90 mg were monitored over 24 hours with an ambulatory blood pressure monitor and were then switched to an equivalent dosage of Nif-CC. After 8 weeks+/-1 week taking Nif-CC, they were again monitored with a 24-hour blood pressure monitor. The 24-hour blood pressure load (percentage of values > 135/85 mm Hg for 24 hrs), daytime blood pressure load (percentage of values > 140/90 mm Hg from 7:00 A.M.-10:00 P.M.), nighttime blood pressure load (percentage of values > 120/80 mm Hg from 10:00 P.M.-7:00 A.M.), diurnal blood pressure variation, average 24-hour blood pressure, daytime blood pressure, nighttime blood pressure, mean blood pressure for the first 4 hours, and last 8 hours of the dosing interval were measured. Adverse effects such as headache, dizziness, and edema were also reported. MEASUREMENTS AND MAIN RESULTS: No differences in average 24 hour-blood pressure readings were observed but significant differences in blood pressure control during the first 4 and last 8 hours of the dosing interval were seen. Systolic and diastolic blood pressures were higher after approximately 16 hours in patients switched from Nif-GITS to Nif-CC. Although Nif-CC caused a greater initial response, it was less effective than Nif-GITS after 16 hours. This could explain the lack of differences in average 24-hour blood pressure values between formulations. Of the 20 patients, 20% experienced increased headaches, 20% showed signs of increased peripheral edema, and 10% reported occasional dizziness after switching agents. Three patients discontinued Nif-CC, two as ordered by their primary care physician and one on his own due to headache. CONCLUSION: This study suggests that patients switched from Nif-GITS to Nif-CC could experience increased blood pressure during the night or toward the end of the dosing interval. They could also experience adverse effects such as headache, edema, and dizziness, which could result in more physician visits and put patients with other disease states such as coronary heart disease at increased risk.
Asunto(s)
Monitoreo Ambulatorio de la Presión Arterial , Bloqueadores de los Canales de Calcio/administración & dosificación , Hipertensión/tratamiento farmacológico , Nifedipino/administración & dosificación , Adulto , Anciano , Bloqueadores de los Canales de Calcio/efectos adversos , Bloqueadores de los Canales de Calcio/farmacocinética , Formas de Dosificación , Femenino , Humanos , Hipertensión/metabolismo , Masculino , Persona de Mediana Edad , Nifedipino/efectos adversos , Nifedipino/farmacocinética , Estudios ProspectivosRESUMEN
Coronary angioplasty is widely performed for the management of symptomatic coronary artery disease. With improvements in technique, operator experience, and tools, more complex lesions are being treated. Unfortunately, luminal renarrowing continues to limit the long-term success of the procedure, resulting in the need for repeat revascularization in approximately 30% of patients within 6 months. As the pathophysiologic process of restenosis is better defined, various pharmacologic and mechanical interventions have been tried to attenuate the process. Some agents are antithrombotics, antiplatelets, angiotensin-converting enzyme inhibitors, lipid-lowering drugs, and calcium channel blockers. Improvement has been noted with the newer glycoprotein IIb- and IIIa-blocking agents, mechanical stents, and radioactive materials. Whether these new compounds will withstand the test of time is unknown.
Asunto(s)
Angioplastia , Enfermedad Coronaria/terapia , Enfermedad Coronaria/patología , Vasos Coronarios/patología , Humanos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/antagonistas & inhibidores , Prevención Secundaria , StentsRESUMEN
STUDY OBJECTIVE: To evaluate the efficacy and safety of atropine in preventing vasovagal reactions (VVRs) during removal of femoral arterial sheaths after diagnostic left heart catheterization. DESIGN: Prospective, double-blind, randomized, placebo-controlled study. SETTING: University-affiliated, 450-bed teaching hospital. PATIENTS: One hundred sixty-five patients undergoing left heart catheterization. INTERVENTIONS: Eighty-eight patients were assigned to receive atropine 0.5 mg intravenously and 77 received placebo 5 minutes before sheath removal. MEASUREMENTS AND MAIN RESULTS: The frequency of VVRs was significantly reduced in the atropine group compared with the placebo group, 2.3% and 10.4%, respectively (overall relative risk in the atropine group 0.22, 95% CI 0.12-0.41, p=0.03). Significant decreases in systolic (35.2 +/- 5.8 mm Hg, p<0.001) and diastolic blood pressures (12.6 +/- 12.6 mm Hg, p=0.002) occurred in the 10 patients with VVRs compared with those without VVR. No cardiac arrhythmias occurred after atropine administration. Dry mouth was the only side effect reported with atropine (8/88, 9%). CONCLUSION: Atropine significantly reduced the frequency of VVRs associated with removal of femoral arterial sheaths after diagnostic left heart catheterization. The drug should be studied in a larger series of patients to assess its ability to decrease the morbidity and costs associated with VVR.
Asunto(s)
Atropina/uso terapéutico , Cateterismo Cardíaco/efectos adversos , Arteria Femoral/cirugía , Antagonistas Muscarínicos/uso terapéutico , Enfermedades Vasculares/prevención & control , Atropina/efectos adversos , Presión Sanguínea/efectos de los fármacos , Método Doble Ciego , Electrocardiografía/efectos de los fármacos , Femenino , Arteria Femoral/inervación , Humanos , Masculino , Persona de Mediana Edad , Antagonistas Muscarínicos/efectos adversos , Estudios Prospectivos , Nervio Vago/efectos de los fármacos , Nervio Vago/fisiología , Enfermedades Vasculares/fisiopatologíaRESUMEN
Histamine2 (H2)-receptor antagonists are widely prescribed for a variety of acid-mediated gastrointestinal disorders. The objective of the present study was to quantify the frequency of inappropriate H2-receptor antagonist use and its economic impact in patients who were admitted to a critical care bed at our hospital and followed as outpatients for 1 year. Eighty-eight (72%) of 123 patients admitted to the coronary care unit (CCU) or the intensive care unit over a 14-day period received H2-receptor antagonists. Forty-five (51%) of the 88 patients did not have a documented indication for H2-receptor antagonist therapy. Most of the patients without indications were admitted to the CCU for cardiac diagnoses. Thirty-eight patients (43%) were discharged on oral H2-receptor antagonist therapy. Twenty (53%) of the 38 patients had no documented indication for therapy; 17 of these patients continued H2-receptor antagonist therapy for 1 year, whereas the remaining 3 patients received therapy for 1, 2, and 3 months, respectively. The cost of therapy for the 45 patients receiving inappropriate therapy during hospitalization was $5,084.31. Outpatients costs for the 20 patients remaining on inappropriate therapy was $8,619.75. The total cost of inappropriate therapy was $13,704.06. If data collected during this 2-week period were extrapolated to 1 year, the projected annual cost of inappropriate therapy would be $356,305.56. The economic impact of inappropriate H2-receptor antagonist therapy at our institution is great. Programs designed to reduce such inappropriate use must be implemented and evaluated for their ability to decrease the associated costs.
Asunto(s)
Instituciones de Atención Ambulatoria/economía , Unidades de Cuidados Coronarios/economía , Antagonistas de los Receptores H2 de la Histamina/economía , Anciano , Alabama , Utilización de Medicamentos/economía , Femenino , Hospitales de Enseñanza , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVE: This study was conducted to evaluate the safety of esmolol in 114 patients treated with thrombolytic therapy for acute myocardial infarction who also had relative contraindications to beta-blockade, and the predictive value of patient tolerance to esmolol and subsequent patient tolerance of oral beta-blocker therapy. PATIENTS: One hundred and fourteen patients with myocardial infarction documented by enzyme concentrations and electrocardiographic changes who also had relative contraindications to beta-blockade. METHODS: Esmolol was initiated during acute myocardial infarction for myocardial ischemia (n = 88), hypertension (n = 13), or supraventricular tachycardia (n = 13). Relative contraindications to beta-blocker therapy included either active signs/symptoms of left ventricular dysfunction or a history of congestive heart failure (n = 40), a history of chronic obstructive pulmonary disease or asthma (n = 31), bradycardia (HR < 60 beats/min; n = 18), peripheral vascular disease (n = 15), or hypotension (systolic BP < 100 mm Hg; n = 14). RESULTS: During initial esmolol dose titration, 69 patients tolerated 300 micrograms/kg/min, 12 patients tolerated 200 micrograms/kg/min, 17 patients tolerated 100 micrograms/kg/min, and 16 patients tolerated 50 micrograms/kg/min. Twenty-eight patients (25 percent) developed dose-limiting adverse effects during esmolol maintenance infusions. Sixteen patients required esmolol dose reduction and 12 required esmolol discontinuation. Adverse effects reversed within 30-45 minutes following dose reduction or discontinuation. The 86 patients who tolerated esmolol infusions without dose reduction or drug discontinuation were subsequently treated with oral beta-blockers. Eleven of these patients (13 percent) developed adverse effects requiring oral beta-blocker discontinuation. Nine of these patients had tolerated only 50 micrograms/kg/min of esmolol, and the other 2 patients had tolerated only 100 micrograms/kg/min. CONCLUSIONS: Esmolol can be used safely in most patients treated with thrombolytic therapy for acute myocardial infarction who have relative contraindications to beta-blockers. Tolerance to higher maintenance doses of esmolol is a good predictor of subsequent outcome with oral beta-blocker therapy.
Asunto(s)
Antagonistas Adrenérgicos beta/uso terapéutico , Infarto del Miocardio/tratamiento farmacológico , Propanolaminas/uso terapéutico , Terapia Trombolítica , Antagonistas Adrenérgicos beta/efectos adversos , Antagonistas Adrenérgicos beta/farmacología , Anciano , Presión Sanguínea/efectos de los fármacos , Contraindicaciones , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Propanolaminas/efectos adversos , Propanolaminas/farmacología , Factores de TiempoRESUMEN
OBJECTIVE: To evaluate the pharmacodynamics of intravenous lidocaine in patients with acute-onset and chronic ventricular arrhythmias. DESIGN: Open-label, pharmacodynamic evaluation. SETTING: Private, university-affiliated, hospital coronary-care unit. PATIENTS: Twenty cardiac patients with acute-onset ventricular ectopy and 20 with chronic ventricular ectopy. INTERVENTIONS: Intravenous lidocaine was administered to all patients as a 1-mg/kg bolus, a 0.5-mg/kg bolus, and a 2.8-mg/min constant infusion for 48 hours. MAIN OUTCOME MEASURES: Changes in ventricular premature beat (VPB) frequency against total treatment period frequency and by an hour-to-hour assessment of changes in VPB frequency compared with total baseline frequencies. Response was defined as greater than or equal to 80 percent total VPB reduction, greater than or equal to 90 percent paired VPB reduction, and total abolition of nonsustained ventricular tachycardia events. RESULTS: A statistically significant difference in the pharmacodynamic effects of lidocaine were observed during the first eight hours of treatment in patients with acute-onset and chronic VPBs. The number of patients with acute-onset VPBs who responded to lidocaine in the first hour of treatment did not change significantly over the remaining hours of treatment. Response to lidocaine was less in patients with chronic VPBs than in patients with acute-onset VPBs. The response rate to lidocaine was significantly less during the first eight hours in patients with chronic VPBs than in patients with acute-onset VPBs. Following eight hours of treatment, the response rates between acute-onset and chronic VPB patients were not significantly different. Mean lidocaine plasma concentrations were not different between the groups. In addition, there were no significant differences in the incidence of adverse effects between the two groups. CONCLUSIONS: The onset of antiarrhythmic effect as measured by suppression of ventricular ectopy is delayed in patients with chronic VPBs compared with patients with acute-onset VPBs. Decisions about lidocaine response in patients with chronic VPBs cannot be made accurately in the first eight hours of therapy.
Asunto(s)
Arritmias Cardíacas/fisiopatología , Lidocaína/farmacología , Enfermedad Aguda , Anciano , Arritmias Cardíacas/tratamiento farmacológico , Enfermedad Crónica , Femenino , Ventrículos Cardíacos , Humanos , Infusiones Intravenosas , Lidocaína/administración & dosificación , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Factores de TiempoRESUMEN
To assess the effects of verapamil on postextrasystolic potentiation (PESP), contrast left ventriculography was performed in ten healthy anesthetized dogs before and after the intravenous administration of verapamil, 0.1 mg/kg. During the contrast ventriculography, a single atrial premature stimulus was introduced. Ejection fractions of a control beat and postpremature beat were measured before and after verapamil. Before verapamil, the mean ejection fractions of the control beat and the postpremature beat were 60 +/- 10 percent and 67 +/- 10 percent, respectively (p less than 0.05). Following the administration of verapamil, the mean ejection fraction of the control beat decreased from 60 +/- 10 percent to 55 +/- 11 percent (p less than 0.05). However, the mean ejection fraction of the postpremature beats increased when compared with the control beats following intravenous verapamil (65 +/- 8 percent and 55 +/- 11 percent, respectively; p less than 0.05). These results suggest that PESP is not inhibited by the administration of intravenous verapamil.
Asunto(s)
Complejos Cardíacos Prematuros/fisiopatología , Verapamilo/farmacología , Animales , Presión Sanguínea/efectos de los fármacos , Perros , Frecuencia Cardíaca/efectos de los fármacos , Contracción Miocárdica/efectos de los fármacos , Volumen Sistólico/efectos de los fármacosRESUMEN
Digoxin causes false-positive ST depression during exercise stress testing, but it is unknown if digoxin produces ST depression during ambulatory electrocardiographic monitoring. Fifty healthy volunteers underwent both exercise stress testing and ambulatory electrocardiographic monitoring before and after 14 days of digoxin (0.25 mg/day) administration. Significant ST depression was defined as greater than or equal to 1 mm of horizontal or downsloping ST depression 80 ms after the J point lasting for greater than or equal to 60 seconds. During therapy, 13 subjects (26%) had at least 1 episode of ST depression and 5 subjects (10%) had multiple episodes of ST depression detected by ambulatory monitoring. Ten subjects (20%) had ST depression that occurred during exercise that was detected by both stress test and ambulatory monitoring. Three subjects (6%) had ST depression that was detected on the ambulatory recording only at times other than during the stress test. Stratification of demographic and clinical variables did not predict digoxin-induced ST depression. Thus, digoxin causes false-positive ST depression detected by ambulatory monitoring. The incidence is similar to that observed during stress testing, but also occurs at heart rates lower than that achieved during stress tests. Ambulatory electrocardiographic monitoring will be less useful in the noninvasive assessment of coronary artery disease in patients receiving digoxin.
Asunto(s)
Digoxina/farmacología , Electrocardiografía Ambulatoria/efectos de los fármacos , Prueba de Esfuerzo/efectos de los fármacos , Adulto , Digoxina/sangre , Humanos , Masculino , Valores de ReferenciaRESUMEN
High-dose intravenous amiodarone was given to 35 patients with recurrent life-threatening ventricular tachycardia (VT) refractory to conventional antiarrhythmic agents. Intravenous amiodarone was given as a 5 mg/kg dose over 30 minutes followed by 20 to 30 mg/kg/day as a constant infusion for 5 days. Twenty-two (63%) patients responded to intravenous amiodarone. All 22 responders received oral amiodarone. Thirteen (59%) continue to receive oral amiodarone after an average follow-up of 19 months, 4 (18%) had sudden cardiac death on oral amiodarone, 2 (9%) died while receiving amiodarone, secondary to left ventricular failure, and 3 (14%) discontinued amiodarone because of side effects. Of the 13 (37%) nonresponders, 10 died in the hospital while receiving intravenous amiodarone, secondary to lethal arrhythmia. Three nonresponders were discharged from the hospital; 2 with automatic cardioverter/defibrillators and 1 receiving a combination of antiarrhythmic agents. Serious adverse events occurred in 13 (37%) patients during intravenous amiodarone therapy. These included hypotension in 8 patients, symptomatic bradycardia in 4 patients and sinus arrest with bradycardia and hypotension in 1 patient. Minor side effects occurred in 23 (66%) patients. In conclusion, high dose intravenous amiodarone is effective in most patients with recurrent, sustained VT but is associated with an unacceptably high incidence of serious adverse events. The optimal dose and duration of intravenous amiodarone for patients with recurrent, refractory sustained VT remain unknown.
Asunto(s)
Amiodarona/uso terapéutico , Taquicardia/tratamiento farmacológico , Administración Oral , Anciano , Amiodarona/administración & dosificación , Amiodarona/efectos adversos , Ensayos Clínicos como Asunto , Tolerancia a Medicamentos , Electrocardiografía , Femenino , Estudios de Seguimiento , Humanos , Infusiones Intravenosas , MasculinoRESUMEN
The effectiveness of nifedipine for the treatment of acute hypertensive episodes in patients already taking chronic calcium-channel blocker therapy is unknown. We report our experience with 43 consecutive patients who received nifedipine for acute hypertensive episodes in the coronary care unit. Of the 43 patients (24 men, 19 women), 23 (53 percent) were taking chronic (greater than 2 mo) calcium-channel blocker therapy. Nifedipine 10 mg capsules were chewed and swallowed with repeat doses given at hourly intervals if necessary. Target BP was 140/90 mm Hg, which was achieved in 31 of 43 patients (72 percent). In patients already taking calcium-channel blockers, target BP was achieved in 18 of 23 patients (78 percent). Response in patients not taking chronic calcium-channel blockers was observed in 13 of 20 patients (65 percent). Overall, adverse effects occurred in 16 of 43 patients (37 percent): 11 of 23 patients (48 percent) taking calcium-channel blockers, and 5 of 20 patients (25 percent) not taking calcium-channel blockers. Nifedipine is equally effective in lowering BP in patients taking calcium-channel blockers as it is in patients not taking them. Although associated with a higher incidence of adverse effects in patients already taking calcium-channel blockers, these effects were not considered serious. Nifedipine is an effective agent in acute hypertensive episodes, even in patients receiving chronic calcium-channel blocker therapy.
Asunto(s)
Hipertensión/tratamiento farmacológico , Nifedipino/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Presión Sanguínea/efectos de los fármacos , Unidades de Cuidados Coronarios , Enfermedad Coronaria/complicaciones , Femenino , Humanos , Hipertensión/etiología , Hipertensión/fisiopatología , Masculino , Persona de Mediana Edad , Nifedipino/efectos adversosRESUMEN
The administration of nifedipine by the sublingual rather than the oral route has been suggested to provide a more rapid onset of effect. We compared the safety and efficacy of sl nifedipine to sl nitroglycerin in patients who developed anginal chest pain during diagnostic exercise stress testing. Consecutive patients undergoing diagnostic Bruce treadmill exercise who had not had a recent myocardial infarction or undergone coronary bypass graft surgery and who were not taking nitrates, beta-blockers, digoxin, or calcium antagonists were eligible. Seventy-eight patients meeting the inclusion/exclusion criteria consented to participate. Of these 78, 13 developed chest pain necessitating exercise cessation and were randomized to either nitroglycerin or nifedipine. Nitroglycerin was initially given to seven patients and nifedipine to six patients. Complete pain relief was observed in five of seven (71 percent) nitroglycerin patients at two minutes postdose. At four minutes postdose, the remaining two nitroglycerin patients were essentially pain-free. At two minutes postdose, no patient receiving nifedipine had complete pain resolution, and only one patient (17 percent) had partial (greater than 50 percent) pain relief. At four minutes postdose, four of the nifedipine patients were crossed over to nitroglycerin. At two minutes after the nitroglycerin dose, all four patients had total pain relief. The remaining two nifedipine patients had partial pain relief and were not crossed over to nitroglycerin. Subjective side effects and changes in heart rate and blood pressure were not significantly different between nitroglycerin and nifedipine.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Angina de Pecho/tratamiento farmacológico , Nifedipino/uso terapéutico , Nitroglicerina/uso terapéutico , Enfermedad Aguda , Administración Sublingual , Adulto , Anciano , Angina de Pecho/fisiopatología , Presión Sanguínea/efectos de los fármacos , Ensayos Clínicos como Asunto , Electrocardiografía , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Nifedipino/administración & dosificación , Nitroglicerina/administración & dosificación , Distribución AleatoriaRESUMEN
This study was designed to compare the efficacy and safety of cibenzoline and quinidine in ambulatory patients with ventricular arrhythmias. Following washout of previous antiarrhythmic treatment, a 48-h ambulatory electrocardiographic (ECG) recording was obtained. Twenty-seven patients were screened, of whom 20 met the entry criteria of greater than or equal to 30 ventricular premature beats (VPBs)/h. Cibenzoline was started at 130 mg every 12 h and was increased to 160 mg every 12 h if necessary. Quinidine was started at 300 mg every 6 h and was increased to 400 mg every 6 h if necessary. Treatment was assessed by 24-h ambulatory ECG recording. Efficacy was defined as greater than 75% reduction in single VPBs, greater than 90% reduction in paired VPBs, and total abolition of ventricular tachycardia events. A 7-day washout with repeat 24-h ambulatory ECG recording to document return of ventricular arrhythmias was required prior to crossover. Efficacy was documented in 9 of 20 (45%) patients receiving cibenzoline and in 9 of 20 (45%) patients receiving quinidine. Response to cibenzoline 130 mg every 12 h was documented in 8 of 20 (40%) patients and in 1 of 11 (9%) patients receiving cibenzoline 160 mg every 12 h. Response to quinidine 300 mg every 6 h was documented in 8 of 20 (40%) patients and in 2 of 6 (33%) patients receiving 400 mg every 6 h. Dose-limiting side effects occurred in 1 of 20 (5%) patients receiving cibenzoline and in 7 of 20 (35%) patients receiving quinidine. Cibenzoline and quinidine are equal in efficacy, but cibenzoline is significantly better tolerated.
Asunto(s)
Antiarrítmicos/uso terapéutico , Arritmias Cardíacas/tratamiento farmacológico , Imidazoles/uso terapéutico , Quinidina/uso terapéutico , Adulto , Anciano , Antiarrítmicos/efectos adversos , Antiarrítmicos/sangre , Enfermedad Crónica , Ensayos Clínicos como Asunto , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos , Humanos , Imidazoles/efectos adversos , Imidazoles/sangre , Masculino , Persona de Mediana Edad , Quinidina/efectos adversos , Quinidina/sangre , Distribución AleatoriaRESUMEN
Angioplasty of anomalous coronary arteries can be technically challenging because of difficulty in selectively cannulating the aberrant vessel. We present our experience with angioplasty of an anomalous right coronary artery. A Judkins-type left coronary catheter with an eccentric tip, the FL4-G type catheter was used to obtain stable position in the right coronary artery and angioplasty was performed.
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Angioplastia de Balón , Anomalías de los Vasos Coronarios/terapia , Angiografía , Angioplastia de Balón/instrumentación , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana EdadRESUMEN
A group of 51 patients with malignant ventricular arrhythmias refractory to standard oral antiarrhythmic agents were treated with oral tocainide. Antiarrhythmic efficacy was defined as total abolition of occurrences of ventricular tachycardia (VT) or ventricular fibrillation (VF) as assessed by hospital admissions for arrhythmias and the occurrence of sudden cardiac death (SCD). Of the 51 patients, 32 (63%) initially tolerated tocainide and were discharged from the hospital. Of the 19 patients not initially responding to tocainide, 6 (12%) had arrhythmia recurrence and 13 (25%) developed intolerable central nervous system or gastrointestinal side effects. Of these 19 short-term nonresponders, 8 (42%) patients suffered SCD over an average follow-up of 24 months (annual SCD rate of 21%). Two patients suffered SCD during the first week of tocainide therapy. Discounting the 2 patients with SCD on tocainide therapy, 6 of 17 (35%) patients initially withdrawn from tocainide suffered SCD (annual SCD rate of 18%). Twenty-four of the 32 short-term responders did not have arrhythmia recurrence over a mean follow-up of 38 months resulting in an overall long-term efficacy of 47% (24/51). Over an average follow-up of 38 months for these 24 short-term responders, 12 patients expired from nonarrhythmic causes, 3 patients were withdrawn for non-drug-related causes, and 9 patients remain on tocainide therapy. Of the 8 long-term nonresponders, 3 patients had arrhythmia recurrence and died suddenly while 5 patients developed intolerable side effects. The annual SCD rate in short-term responders was 3%. Eighteen of the 51 patients (35%) were withdrawn from the study because of adverse effects.(ABSTRACT TRUNCATED AT 250 WORDS)
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Lidocaína/análogos & derivados , Taquicardia/tratamiento farmacológico , Fibrilación Ventricular/tratamiento farmacológico , Muerte Súbita/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Cinética , Lidocaína/metabolismo , Lidocaína/uso terapéutico , Lidocaína/toxicidad , Masculino , Persona de Mediana Edad , Recurrencia , Factores de Tiempo , TocainidaRESUMEN
The efficacy and safety of intravenous tocainide were compared with intravenous lidocaine in patients with chronic ventricular arrhythmias in a double-blind, parallel study. Twenty-nine patients were randomized to a tocainide (n = 15) or lidocaine (n = 14) group. Antiarrhythmic efficacy was defined as a greater than or equal to 50% reduction in single ventricular premature complex (VPC) frequency, greater than or equal to 90% reduction in paired VPC frequency, and total abolition of ventricular tachycardia. Efficacy was observed in 40% (6 of 15) of patients in the tocainide group and in 36% (5 of 14) patients in the lidocaine group. A 75% or greater reduction in total VPCs occurred in 40% (6 of 15) of patients in the tocainide group and in 57% (8 of 14) of patients in the lidocaine group. Greater than 90% suppression of paired VPCs occurred in 9 of 13 (69%) patients taking tocainide and in 6 of 11 (54%) patients taking lidocaine. Total abolition of ventricular tachycardia was documented in 5 of 11 (45%) patients given tocainide and in two of six (33%) patients given lidocaine. A total of 17 adverse reactions affecting 86% (12 of 14) of patients taking lidocaine and 11 adverse reactions affecting 53% (8 of 15) of patients taking tocainide occurred. Four patients in each treatment group suffered dose-limiting adverse effects. This study suggests that the efficacy and safety of intravenous tocainide are similar to that of intravenous lidocaine in patients with chronic ventricular arrhythmias.
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Antiarrítmicos/uso terapéutico , Arritmias Cardíacas/tratamiento farmacológico , Lidocaína/análogos & derivados , Lidocaína/uso terapéutico , Antiarrítmicos/administración & dosificación , Antiarrítmicos/efectos adversos , Arritmias Cardíacas/fisiopatología , Enfermedad Crónica , Ensayos Clínicos como Asunto , Método Doble Ciego , Femenino , Humanos , Inyecciones Intravenosas , Lidocaína/administración & dosificación , Lidocaína/efectos adversos , Masculino , Distribución Aleatoria , TocainidaRESUMEN
This single-blind, placebo-controlled study evaluated long-term therapy with cibenzoline in 19 patients with chronic ventricular arrhythmias. Antiarrhythmic efficacy, defined as greater than or equal to 75% reduction in single premature ventricular complexes (PVCs), greater than or equal to 90% reduction in paired PVCs, and total abolition of ventricular tachycardia (VT), was established after dose titration in 14 of 19 (74%) patients. Mean frequency of single PVCs was reduced by 65%, mean paired PVC frequency was reduced by 68%, and mean VT event frequency was reduced by 82%. Antiarrhythmic efficacy was maintained during long-term therapy in five of the 14 (36%) short-term responders. Of the nine patients who discontinued cibenzoline during long-term follow-up, five had a loss of arrhythmia control, three failed to redevelop arrhythmias during placebo reintroduction, and one developed an adverse reaction. Three patients (16%) experienced a proarrhythmic effect. Echocardiographic evaluation did not reveal any deleterious effect of cibenzoline on left ventricular function in the group as a whole. In six patients with preexisting left ventricular dysfunction, left ventricular ejection fraction and fractional shortening improved significantly (P less than .05) during cibenzoline therapy. Adverse effects occurred in seven patients (37%) but necessitated drug discontinuation in only one patient (5%). Cibenzoline provides effective short-term therapy for patients with chronic ventricular arrhythmias. Long-term therapy must be assessed periodically to ensure continued efficacy. Drug-related adverse effects occur infrequently. Cibenzoline can be used safely in patients with compensated left ventricular dysfunction.