American journal of therapeutics
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Dynamic left ventricular outflow tract obstruction occurs in hypertrophic cardiomyopathy, stress cardiomyopathy, acute coronary syndromes, and with inotrope use. We describe three critical care patients who developed "isolated" left ventricular outflow tract obstruction with hypotension in the absence of these precipitants. Systolic anterior motion of anterior mitral valve leaflet with peak left ventricular outflow tract gradients of greater than 120 mmHg was noted in Cases 1 and 2. ⋯ Bedside Doppler echocardiogram confirmed near normalization of left ventricular outflow tract gradient with improvement in systolic anterior motion and hypotension within minutes after IV β blocker confirming its specific therapeutic effect. Isolated left ventricular outflow tract obstruction can occur in the absence of recognized precipitants. Early recognition is crucial because this potentially fatal condition responds well to adequate β blocker and IV fluids with rapid relief of hypotension and symptoms.
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Sulfobutylether-β-cyclodextrin (SBE-CD) is a pharmaceutical excipient known to bind verapamil. After intravenous administration, clearance of SBE-CD approximates glomerular filtration rate. We hypothesized that SBE-CD would complex with verapamil in vivo, enhance renal elimination, and increase time to death in a rat model of verapamil toxicity. ⋯ Verapamil poisoned rats treated with 2.25 g/kg of SBE-CD showed increased toxicity. We propose that this effect was related to the large hyperosmolar CD infusion combined with verapamil-induced cardiogenic shock. Additional studies are warranted to clarify the mechanism of increased toxicity in our study and to assess for potential beneficial effects at lower SBE-CD concentrations.
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Perioperative management of patients on chronic anticoagulant use involves balancing individual risk for thromboembolism and bleeding. Discontinuation of antithrombotic therapy can place patients at increased risk of thromboembolic complications, whereas continuing antithrombotic therapy can increase procedure-related bleeding risk. Temporary perioperative substitution of low-molecular weight heparin or unfractionated heparin in place of warfarin, "the bridge therapy" is often used in the periprocedural period, but the indications and timing of this is still uncertain. This review addresses the risk stratification of patients according to thromboembolic risk, indications, timing, and duration, and a practical approach to bridge therapy.
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Thirty-six million Americans older than 12 years of age have used cocaine in their lifetime. Cocaine abuse is on the rise and it brings the challenges to treat the complication associated with it, particularly cardiovascular complications. As the understanding of pathophysiology of cocaine-associated cardiovascular complications is advancing, the treatment modalities are also modifying. In this article, common cardiovascular complications associated with acute or chronic cocaine use and their treatment are reviewed.
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Shoulder pain following thoracotomy is a common postoperative complaint and can be difficult to treat. This article explores how to select patients who would benefit from a suprascapular nerve block for post-thoracotomy shoulder pain. A retrospective case review of 178 patients who underwent thoracotomy at our institution was performed. ⋯ Twenty-nine of 34 (85.3%) patients obtained satisfactory pain relief. We estimate a true-positive rate of 85.3% with a 95% confidence interval of (68.9%, 95.0%) for those patients who received relief from suprascapular nerve block after localizing signs on physical examination of the shoulder. Patients post-thoracotomy with local signs of shoulder pain on physical examination may benefit from suprascapular nerve blocks in the immediate postoperative period.