The American journal of cardiology
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Combined dyslipidemia is the concurrent presence of multiple abnormalities in various lipid subfractions, including elevated concentrations of low-density lipoprotein (LDL) cholesterol and triglycerides (TGs), as well as decreased concentrations of high-density lipoprotein (HDL) cholesterol. The Adult Treatment Panel III (ATP III) guidelines of the US National Cholesterol Education Program (NCEP) lowered the cut points for classification of TG levels, established non-HDL cholesterol levels as a secondary target of therapy in patients with TGs of >or=2.26 mmol/L (200 mg/dL), and defined the metabolic syndrome as a secondary target of therapy. Although 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are first-line therapy for most patients with elevated LDL cholesterol, statin monotherapy may not be sufficient to achieve recommended non-HDL cholesterol goals, and statins have only modest effects on reducing TG levels. ⋯ In a number of small studies, the combination of statins and omega-3 fatty acids has been consistently shown to be an effective, safe, and well-tolerated treatment for combined dyslipidemia. Patients with recent myocardial infarction may also benefit from this combination. When considering risks and benefits of adding a second agent to statins for treatment of combined dyslipidemia, omega-3 fatty acids provide additional lipid improvements without requiring additional laboratory tests and do not increase risk for adverse muscle or liver effects.
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It is widely accepted by medical practitioners that diabetes is a major independent risk factor for the development of cardiovascular disease. However, less attention has been directed toward elevated blood glucose as a predictor of poor outcomes in hospitalized patients in cardiac critical care. This has occurred despite documentation of hyperglycemia in a significant proportion of patients admitted for cardiac care and considerable data supporting the use of intravenous (IV) insulin to achieve glycemic control. ⋯ Nonetheless, transition from IV to subcutaneous therapy must occur at some point during the hospital stay. In conclusion, the implementation of measures to achieve glycemic control in acute cardiac care hospital settings can significantly reduce morbidity and mortality and can substantially decrease the costs associated with prolonged hospital stays. This report reviews recent clinical data on the benefits of IV insulin infusion in cardiac patients in critical care and provides recommendations on transitioning patients from IV insulin infusion to subcutaneous therapy.
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Comparative Study
Three-phase model of cardiac arrest: time-dependent benefit of bystander cardiopulmonary resuscitation.
Evidence has suggested that the pathophysiology of ventricular fibrillation cardiac arrest may consist of 3 time-sensitive phases: electrical, circulatory, and metabolic. We performed a retrospective cohort study of adults in a metropolitan county who had had witnessed ventricular fibrillation arrest before emergency medical services were undertaken to investigate this 3-phase model with regard to bystander cardiopulmonary resuscitation (CPR). We hypothesized that the survival benefit from bystander CPR depends on the collapse-to-shock interval, with the highest benefit occurring during the circulatory phase. ⋯ The bystander CPR was associated with an OR of survival of 0.96 (95% CI 0.64 to 1.46) for a 1- to 5-minute collapse-to shock interval, OR of 1.25 (95% CI 1.00 to 1.58) for a 6- to 7-minute interval, OR of 1.62 (95% CI 1.25 to 2.11) for an 8- to 10-minute interval, and OR of 2.11 (95% CI 1.32 to 3.37) for an > or = 11-minute interval. The results of this investigation support a phased model of ventricular fibrillation arrest. The findings suggest that the transition from the electrical to circulatory phase may occur at about 5 minutes, and the circulatory phase may extend to 15 minutes.
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Comparative Study
Comparison of plasma B-type natriuretic peptide levels in single ventricle patients with systemic ventricle heart failure versus isolated cavopulmonary failure.
The measurement of plasma B-type natriuretic peptide (BNP) has emerged as a useful biomarker of heart failure in patients with cardiomyopathy. The pathophysiology of heart failure in single ventricle (SV) circulation may be distinct from that of cardiomyopathies. A distinct pattern of BNP elevation in heart failure in the SV population was hypothesized: it is elevated in heart failure secondary to ventricular dysfunction but not in isolated cavopulmonary failure. ⋯ Excluding the group with cavopulmonary failure, the severity of heart failure from systemic ventricular dysfunction was associated with plasma BNP. In conclusion, plasma BNP is elevated in SV patients with systemic ventricular or left-sided cardiac failure. BNP is not elevated in patients missing a pulmonary ventricle with isolated cavopulmonary failure.
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N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP) is well established as a predictor of prognosis in patients with left ventricular dysfunction. Although a similar prognostic significance has been suggested in 1 study of right ventricular failure and idiopathic pulmonary arterial hypertension, NT-pro-BNP has not been assessed as a marker of disease severity in a more heterogenous group of patients with chronic precapillary pulmonary hypertension (PH). Hence, this study assessed plasma NT-pro-BNP and other clinical variables in 61 consecutively recruited patients with various forms of chronic precapillary PH. ⋯ Baseline NT-pro-BNP was an independent predictor of mortality. Kaplan-Meier survival analysis according to the median value of NT-pro-BNP (168 pmol/L) demonstrated a significantly higher mortality rate in those with supramedian values than in those with low plasma levels (p = 0.010). In conclusion, these findings suggest that in a heterogenous group of patients with chronic precapillary PH, plasma NT-pro-BNP can be used to determine the clinical severity of disease and is independently associated with long-term mortality.