cardiovascular-agents and Hypotension

Perioperative phases of hypotension are associated with an increase in postoperative complications and organ damage. Whereas some years ago hemodynamic stabilization was primarily carried out by volume supplementation, in recent years the use and dosing of cardiovascular-active substances has significantly increased. But like intravascular volume therapy, also substances with a cardiovascular effect have therapeutic margins, and thus, potential side effects. This review article discusses indications for each cardiovascular-active agent, weighing up advantages and disadvantages. Special attention is paid to the question how to administrate them: central venous catheter vs. peripheral indwelling venous cannula. The authors come to the conclusion that it is not a question of whether it is principally allowed to apply cardiovascular-active drugs via peripheral veins but more importantly, what should be taken into consideration if a peripheral venous access is used. This article provides concise recommendations.. Perioperative hypotensive Phasen sind mit der Zunahme von postoperativen Komplikationen und Organschäden assoziiert. Während noch vor einigen Jahren die hämodynamische Stabilisierung in erster Linie durch Volumengaben geprägt war, haben in letzter Zeit der Einsatz und auch die Dosierung kardiovaskulär aktiver Substanzen deutlich zugenommen. Wie für die intravasale Volumentherapie gilt auch für die Therapie mithilfe Herz-Kreislauf-wirksamer Substanzen, dass diese aufgrund ihrer geringen therapeutischen Breite Nebenwirkungen haben. Im vorliegenden Übersichtsbeitrag werden konkrete Indikationen der einzelnen kardiovaskulär aktiven Wirkstoffe mit den jeweiligen Vor- und Nachteilen diskutiert. Besonderer Fokus liegt auf der Fragestellung der Applikationsform: zentraler Venenkatheter vs. periphere Venenverweilkanüle. Die Autoren kommen zu dem Schluss, dass sich nicht die Frage stellt, ob es prinzipiell erlaubt ist, Herz-Kreislauf wirksame Medikamente periphervenös zu applizieren, sondern vielmehr, was dabei zu beachten ist. Der Beitrag gibt entsprechende Empfehlungen.

Topics: Cardiovascular Agents; Catheterization, Central Venous; Central Venous Catheters; Hemodynamics; Humans; Hypotension

To perform a systematic review of the techniques for transient circulatory arrest during intracerebral aneurysm surgery according to the PRISMA guidelines. Search of PubMed and Google Scholar using the following: ("heart arrest" OR "cardiac standstill"[All Fields]) AND ("intracranial aneurysm" OR "intracranial"[All Fields] AND "aneurysm"[All Fields]). A total of 41 original articles were retrieved, of which 17 were excluded (review articles, editorials and single-case reports). A total of 24 separate articles published between 1984 and 2018 were included in the final analysis, where the majority of patients harbored anterior circulation giant or large aneurysms. Adenosine-induced cardiac arrest gave a short, temporary asystole. The method had benefits in aneurysm with a broad neck, a thin wall, in specific localizations with narrow surgical corridors or in case of intraoperative rupture. Rapid ventricular pacing (RVP) allows a longer and more easily controlled hypotension. Its use is largely limited to elective cases. Deep hypothermic circulatory arrest required a complex infrastructure, and fatal procedure complications lead to a 11.5-30% 30-day mortality rate, limiting its application to giant or complex aneurysm of the basilar artery or to residual posterior circulation aneurysm after endovascular treatment. Adenosine and RVP are both effective options to facilitate clipping of complex aneurysms. However, their use in patient with ischemic heart disease and cardiac arrhythmias should be avoided, and their safety in the context of subarachnoid hemorrhage is yet to be determined. Today, deep hypothermic circulatory arrest is almost obsolete due to endovascular alternatives.

Topics: Adenosine; Cardiac Pacing, Artificial; Cardiovascular Agents; Circulatory Arrest, Deep Hypothermia Induced; Heart Arrest, Induced; Humans; Hypotension; Intracranial Aneurysm; Neurosurgical Procedures

: We aimed to combine evidence from all heart failure trials that have investigated the effects of drugs with blood pressure (BP)-lowering properties to assess the extent to which such drugs reduce BP in heart failure, the association between the net change in BP between treatment arms and cause-specific outcomes and whether treatment effects (efficacy and safety) vary according to baseline BP. We conducted a systematic review and meta-analysis including randomized clinical trials of drugs with BP-lowering properties in patients with chronic heart failure with at least 300 patient-years follow-up. We included a total of 37 trials (91 950 patients) and showed that treatment with drugs with BP-lowering properties resulted in a small but significant decrease in SBP in patients with heart failure with no evidence that the efficacy and safety of those drugs varied according to baseline BP.

Topics: Blood Pressure; Cardiovascular Agents; Heart Failure; Humans; Hypotension; Randomized Controlled Trials as Topic

Ivabradine is a blocker of the funny current channels in the sinoatrial node cells. This results in pure heart rate reduction when elevated without direct effect on contractility or on the vessels. It was tested in a large outcome clinical trial in stable chronic heart failure (CHF) with low ejection fraction, in sinus rhythm, on a contemporary background therapy including betablockers (SHIFT: Systolic Heart Failure Treatment with the If inhibitor Trial).The primary composite endpoint (cardiovascular mortality or heart failure hospitalization) was reduced by 18% whereas the first occurrence of heart failure hospitalizations was reduced by 26%. The effect was of greater magnitude in patients with baseline heart rate ≥75 beats per minute. Ivabradine improved also the quality of life and induced a reverse remodelling.The safety was overall good with an increase in (a)symptomatic bradycardia and visual side effects.The efficacy and tolerability were similar to those observed in the overall trial in subgroups with diabetes mellitus, low systolic blood pressure (SBP), renal dysfunction or chronic obstructive pulmonary disease (COPD).Ivabradine is indicated in CHF with systolic dysfunction, in patients in sinus rhythm with a heart rate ≥75 bpm in combination with standard therapy including betablocker therapy or when betablocker therapy is contraindicated or not tolerated (European Medicine Agency).

Topics: Benzazepines; Cardiovascular Agents; Comorbidity; Diabetes Mellitus; Heart Failure; Hemodynamics; Hospitalization; Humans; Hypotension; Ivabradine; Pulmonary Disease, Chronic Obstructive; Quality of Life; Renal Insufficiency; Treatment Outcome

Primary neurodegenerative autonomic disorders are characterized clinically by loss of autonomic regulation of blood pressure. The clinical picture is dominated by orthostatic hypotension, but supine hypertension is also a significant problem. Autonomic failure can result from impairment of central autonomic pathways (multiple system atrophy) or neurodegeneration of peripheral postganglionic autonomic fibers (pure autonomic failure, Parkinson's disease). Pharmacologic probes such as the ganglionic blocker trimethaphan can help us in the understanding of the underlying pathophysiology and diagnosis of these disorders. Conversely, understanding the pathophysiology is crucial in the development of effective pharmacotherapy for these patients. Autonomic failure patients provide us with an unfortunate but unique research model characterized by loss of baroreflex buffering. This greatly magnifies the effect of stimuli that would not be apparent in normal subjects. An example of this is the discovery of the osmopressor reflex: ingestion of water increases blood pressure by 30-40 mm Hg in autonomic failure patients. Animal studies indicate that the trigger of this reflex is related to hypo-osmolality in the portal circulation involving transient receptor potential vanilloid 4 receptors. Studies in autonomic failure patients have also revealed that angiotensin II can be generated through noncanonical pathways independent of plasma renin activity to contribute to hypertension. Similarly, the mineralocorticoid receptor antagonist eplerenone produces acute hypotensive effects, highlighting the presence of non-nuclear mineralocorticoid receptor pathways. These are examples of careful clinical research that integrates pathophysiology and pharmacology to advance our knowledge of human disease.

Topics: Animals; Autonomic Agents; Autonomic Nervous System; Autonomic Nervous System Diseases; Baroreflex; Blood Pressure; Cardiovascular Agents; Cardiovascular System; Ganglionic Blockers; Humans; Hypertension; Hypotension; Neurotransmitter Agents; Nitric Oxide; Renin-Angiotensin System; Supine Position; Sympathomimetics; Vasoconstrictor Agents

Topics: Animals; Cardiovascular Agents; Drug Design; Heart Failure; Hemodynamics; Humans; Hypotension; Risk Assessment; Risk Factors; Stroke Volume; Ventricular Function, Left; Ventricular Remodeling

This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.

Topics: Airway Management; Cardiopulmonary Resuscitation; Cardiovascular Agents; Critical Care; Early Medical Intervention; Electric Countershock; Emergency Medical Services; Female; Fetal Death; Heart Arrest; Humans; Hypotension; Hypoxia; Infant, Newborn; Oxygen Inhalation Therapy; Patient Positioning; Pregnancy; Pregnancy Complications, Cardiovascular

Acute cardiogenic pulmonary edema and cardiogenic shock are two of the main forms of presentation of acute heart failure. Both entities are serious, with high mortality, and require early diagnosis and prompt and aggressive management. Acute pulmonary edema is due to the passage of fluid through the alveolarcapillary membrane and is usually the result of an acute cardiac episode. Correct evaluation and clinical identification of the process is essential in the management of acute pulmonary edema. The initial aim of treatment is to ensure hemodynamic stability and to correct hypoxemia. Other measures that can be used are vasodilators such as nitroglycerin, loop diuretics and, in specific instances, opioids. Cardiogenic shock is characterized by sustained hypoperfusion, pulmonary wedge pressure > 18 mmHg and a cardiac index < 2.2l/min/m(2). The process typically presents with hypotension (systolic blood pressure < 90 mmHg or a decrease in mean arterial pressure > 30 mmHg) and absent or reduced diuresis (< 0.5 ml/kg/h). The most common cause is left ventricular failure due to acute myocardial infarction. Treatment consists of general measures to reverse acidosis and hypoxemia, as well as the use of vasopressors and inotropic drugs. Early coronary revascularization has been demonstrated to improve survival in shock associated with ischaemic heart disease.

Topics: Acute Disease; Cardiovascular Agents; Combined Modality Therapy; Diagnosis, Differential; Diuresis; Heart Failure; Humans; Hypotension; Hypoxia; Myocardial Infarction; Myocardial Revascularization; Narcotics; Oxygen Inhalation Therapy; Pulmonary Edema; Respiration, Artificial; Sepsis; Shock; Shock, Cardiogenic; Sodium Potassium Chloride Symporter Inhibitors; Vasoconstrictor Agents; Vasodilator Agents; Ventricular Dysfunction, Left

Despite obvious achievements during last decades in studies of pathogenesis and search for effective ways of treatment of chronic heart failure (CHF) it remains one of most severe and prognostically unfavorable diseases of the cardiovascular system. Thereby determination of predictors of death and detection of high risk patients for more active drug interventions on CHF progression appears to be actual. It has been shown in a number of epidemiological and cohort studies that low arterial pressure (AP) serves as an independent risk factor of prognosis in patients with CHF. In this paper we present short literature review on this theme, consideration of possible mechanisms of negative effect of arterial hypotension on function of vitally important organs in patients with CHF, and summation of data of studies which have demonstrated relationship between low level of AP and worsening of prognosis.

Topics: Cardiovascular Agents; Cardiovascular System; Chronic Disease; Death; Heart Failure; Humans; Hypotension; Meta-Analysis as Topic; Organs at Risk; Prognosis; Risk Factors

Hypotension in anesthesia and obstetric anesthesia in particular, is a widespread problem. After the temporary withdrawal of Akrinor from the market, the internationally available drug ephedrine is available for prevention and therapy of hypotension in anesthesia and its effect is comparable with Akrinor. In obstetric epidural anesthesia the intravenous prophylactic drug application of ephedrine seems to be superior to therapeutic application only. The aim of this overview is to show alternatives to the currently administered catecholamines for prevention of hypotension in obstetric anesthesia.

Topics: Acidosis; Adult; Anesthesia, Conduction; Anesthesia, Epidural; Anesthesia, Obstetrical; Cardiovascular Agents; Drug Combinations; Ephedrine; Female; Humans; Hypotension; Infant, Newborn; Pregnancy; Theophylline; Vasoconstrictor Agents

Successful management of neonatal shock is driven by the etiology and pathophysiology of the cardiovascular compromise. In the clinical practice, however, we only have a limited ability to recognize the etiology of the condition (hypovolemia, myocardial dysfunction or abnormal vasoregulation). Therefore, management is based on administration of fluid boluses and vasoactive medications according to personal preference rather than to the underlying pathophysiology. In addition, although management strategies aimed at improving systemic blood pressure may have been associated with a decrease in mortality in critically ill neonates, there are no prospective data on the effect of these management strategies on morbidity, especially on long-term neurodevelopmental outcome. This paper briefly reviews some of the more frequently encountered clinical presentations of neonatal shock and describes the developmentally regulated cardiovascular responses to the pathophysiology-driven management strategies used in these clinical presentations in the critically ill preterm and term neonate.

Topics: Cardiotonic Agents; Cardiovascular Agents; Humans; Hypotension; Infant, Newborn; Infant, Newborn, Diseases; Shock

In the beagle dog, exaggerated hypotension and tachycardia following administration of high doses of vasodilating antihypertensive drugs are associated with vascular injury and characteristic patterns of myocardial necrosis and haemorrhage. Cardiac and vascular inflammation and necrosis also occur in dogs in association with different functional changes including severe hypertension and the effects that follow treatment with high doses of vasoconstrictor and pressor drugs. More recently, cardioactive drugs of novel classes such as the endothelin antagonists have also been shown to produce vascular damage in the beagle dog but in the absence of ischaemic myocardial damage or significant haemodynamic alterations that typically follow administration of high doses of vasodilating antihypertensive or pressor drugs. This underlines the importance of a careful analysis of the patterns of cardiovascular pathology, their dose, temporal and spatial relationships in the context of functional changes.

Topics: Animals; Arteritis; Cardiovascular Agents; Dogs; Endothelins; Humans; Hypertension; Hypotension; Muscle, Smooth, Vascular

Cardiovascular diseases remain the leading cause of death in ESRF patients. Coronary risk factors such as hypertension and lipid abnormalities are prevalent in the dialysis population and may be difficult to control. Special factors contributing to the imbalance between myocardial oxygen supply and demand include anemia, arteriovenous fistula, and the hemodialysis procedure itself. LVH and left ventricular dilation frequently result in symptomatic CHF. Atrial and ventricular arrhythmias are common; pericarditis may also occur. Control of the extracellular fluid volume through ultrafiltration with dialysis and the dietary avoidance of salt and water is critical to controlling hypertension in the dialysis population. The potential for drug side effects and the altered pharmacokinetics of medications in renal failure patients should be considered when prescribing cardiovascular drugs.

Topics: Cardiovascular Agents; Heart Diseases; Humans; Hypertension, Renal; Hypotension; Kidney Failure, Chronic; Renal Dialysis; Risk Factors

Low systolic blood pressure (SBP) is associated with poor outcomes in heart failure and complicates management. In a post hoc analysis, we investigated the efficacy and safety of ivabradine in the SHIFT population divided by tertiles of baseline SBP.. The analysis comprised 2110 patients with SBP <115 mmHg, 1968 with 115≤ SBP <130 mmHg, and 2427 with SBP ≥130 mmHg. Patients with low SBP were younger, had lower ejection fraction, and were less likely to be at target beta-blocker dose than patients in the other SBP groups. Ivabradine was associated with a similar relative risk reduction of the composite outcome in the three SBP groups [SBP <115 mmHg, hazard ratio (HR) = 0.84, 95% confidence interval (CI) 0.72-0.98; 115≤ SBP <130 mmHg, HR = 0.86, 95% CI 0.72 to 1.03; SBP ≥130 mmHg, HR = 0.77, 95% CI 0.66 to 0.92; P interaction = 0.68]. Similar results were found for cardiovascular mortality (P interaction = 0.91), hospitalization because of heart failure (P interaction = 0.79), all-cause mortality (P interaction = 0.90), and heart failure mortality (P interaction = 0.18). There was no evidence for a difference in safety profile according to SBP group.. The efficacy and safety of ivabradine is independent of SBP. This may have implications for the management of HF patients with low SBP and elevated heart rate.

Topics: Aged; Benzazepines; Blood Pressure; Cardiovascular Agents; Double-Blind Method; Female; Heart Failure, Systolic; Humans; Hypertension; Hypotension; Ivabradine; Male; Middle Aged; Prognosis; Systole; Treatment Outcome

Although congestion is the main reason for admission in patients with worsening acute heart failure syndromes, patients presenting with low SBP and renal impairment often do not respond adequately to and may not tolerate traditional diuretic therapy. We sought to determine the short-term hemodynamic effects of tolvaptan in this high-risk population.. In a subset analysis of the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan trial, 759 patients (18% of total) had elevated blood urea nitrogen (BUN) (> 20  mg/dl) and low SBP (<105  mmHg) at admission. Of these, 386 were randomized to tolvaptan and 373 to placebo.. Demographics and baseline characteristics were similar in both groups. Greater reductions from baseline in body weight were observed for tolvaptan (1.63 ±  2.00 vs. 0.76  ±  1.75  kg, P  <  0.0001 at day 1 and 3.23  ±  3.36 vs. 2.10  ±  3.47  kg, P  <  0.0001 at day 7 or discharge). Greater increases in serum sodium concentration were also observed in the tolvaptan group as early as day 1 (4.41  ±  3.67 vs. 1.32  ±  3.93  mEq/l, P  <  0.0001) and persisted through day 7 or discharge (4.79  ±  4.89 vs. 1.25  ±  5.00  mEq/l, P  <  0.0001). Similarly, improvements in patient-reported dyspnea and investigator-assessed orthopnea were significantly greater in the tolvaptan group as early as day 1 of treatment. These changes were not associated with significant differences in heart rate, SBP, DBP or serum creatinine between patients in the two treatment groups during hospitalization. In-hospital mortality rates (total and cause-specific) were comparable to patients who had presented with SBP more than 105  mmHg and BUN less than 20  mg/dl.. In this subgroup analysis of patients with hypotension and renal impairment, tolvaptan improved symptoms, reduced body weight and increased serum sodium as early as inpatient day 1 without adversely affecting blood pressure or renal function.

Topics: Administration, Oral; Adult; Aged; Aged, 80 and over; Antidiuretic Hormone Receptor Antagonists; Benzazepines; Cardiovascular Agents; Diuretics; Double-Blind Method; Drug Therapy, Combination; Female; Furosemide; Heart Failure; Humans; Hypotension; Male; Middle Aged; Renal Insufficiency; Sodium; Tolvaptan; Treatment Outcome

We previously reported that the fixed-dose combination of isosorbide dinitrate and hydralazine hydrochloride (FDC I/H) significantly decreased the risk of all-cause death and first hospitalization for heart failure (HF) and improved quality of life in patients with New York Heart Association class III or IV heart failure in the African-American Heart Failure Trial (A-HeFT). The current analyses further define the effect of FDC I/H on the timing of event-free survival (mortality or first hospitalization for HF) and time to first hospitalization for HF, as well as effects by subgroups and effects on cause-specific mortality.. Kaplan-Meier analyses of the 1050 A-HeFT patients on standard neurohormonal blockade demonstrated that FDC I/H produced a 37% improvement in event-free survival (P<0.001) and a 39% reduction in the risk for first hospitalization for HF (P<0.001). These benefits appeared to emerge early (at approximately 50 days of treatment) and were sustained through the duration of the trial. Subgroup analyses of treatment effect by age, sex, baseline blood pressure, history of chronic renal insufficiency, presence of diabetes mellitus, cause of HF, and baseline medication usage demonstrated consistent beneficial effect of FDC I/H on the primary composite score and event-free survival across all subgroups. Mortality from pump failure was reduced by 75% (P=0.012).. FDC I/H treatment of black patients with moderate to severe HF who were taking neurohormonal blockers produced early and sustained significant improvement in event-free survival and hospitalization for HF in the A-HeFT cohort, with significant reduction in mortality from cardiovascular and pump failure deaths. The treatment effects on the primary composite end point and event-free survival were consistent across subgroups.

Topics: Adult; Aged; Arthralgia; Biomarkers; Black or African American; Cardiovascular Agents; Cause of Death; Disease-Free Survival; Dizziness; Double-Blind Method; Drug Combinations; Heart Failure; Heart Transplantation; Hospitalization; Humans; Hydralazine; Hypotension; Isosorbide Dinitrate; Kaplan-Meier Estimate; Middle Aged; Mortality; Natriuretic Peptide, Brain; Nitric Oxide Donors; Proportional Hazards Models; Quality of Life; Surveys and Questionnaires; Treatment Outcome; Vasodilator Agents

The renin-angiotensin system plays an important part in the pathogenesis of congestive heart failure (CHF). This study evaluated the effect of an angiotensin II type 1 receptor antagonist on exercise tolerance and symptoms of CHF.. In this multicenter, double-blind, parallel-group study, 844 patients with CHF were randomized to 12 weeks' treatment with placebo (n=211) or candesartan cilexetil 4 mg (n=208), 8 mg (n=212), or 16 mg (n=213) after a 4-week placebo run-in period. Changes in exercise time, Dyspnea Fatigue Index score, NYHA functional class, and cardiothoracic ratio were determined. Candesartan cilexetil produced a dose-related improvement in exercise time. For the intention-to-treat population, the increase produced by candesartan cilexetil 16 mg was significantly greater than that produced by placebo (47.2 versus 30.8 seconds, P=0.0463). All doses of candesartan cilexetil significantly improved the Dyspnea Fatigue Index score relative to placebo. NYHA class improved more frequently in the candesartan cilexetil groups; the differences relative to placebo were not significant. The decrease in cardiothoracic ratio with candesartan 4 to 16 mg was small but statistically significant compared with placebo (all P<0.05). In all candesartan cilexetil groups, plasma renin activity and angiotensin II levels increased from baseline and aldosterone levels decreased in the 8- and 16-mg treatment groups. Candesartan cilexetil was well tolerated at all doses.. In summary, treatment with candesartan cilexetil demonstrated significant improvements in exercise tolerance, cardiothoracic ratio, and symptoms and signs of CHF and was well tolerated.

Topics: Adult; Aged; Aged, 80 and over; Angiotensin II; Angiotensin Receptor Antagonists; Antihypertensive Agents; Benzimidazoles; Biphenyl Compounds; Cardiovascular Agents; Dose-Response Relationship, Drug; Double-Blind Method; Drug Interactions; Dyspnea; Exercise Test; Exercise Tolerance; Fatigue; Female; Heart Failure; Humans; Hypotension; Male; Middle Aged; Prospective Studies; Receptor, Angiotensin, Type 1; Receptor, Angiotensin, Type 2; Renin; Severity of Illness Index; Tetrazoles

Topics: Cardiovascular Agents; Epoprostenol; Humans; Hypotension; Iloprost; Male; Middle Aged; Platelet Aggregation

Thirty in-patients with chronically reduced arterial blood pressure and relevant subjective symptoms were treated over a 15-day period with oral doses of either 400 mg dimetophrine twice daily or placebo, according to a prospective, randomized, double-blind design. Systolic and diastolic blood pressures and heart rate were monitored at 5-day interval: subjective specific symptoms (scored 0 to 3 in order of increasing severity), haematology and haematochemistry were recorded before and after treatment. Both systolic and diastolic blood pressures increased significantly after dimetophrine all through the observation period. After 5 days, systolic blood pressure had already reached significantly higher values in comparison with the placebo-treated group, as did diastolic blood pressure by the 10th day. Overall, during the observation period, an increase from 82.7 +/- 1.0 to 112.3 +/- 2.1 mmHg was observed in systolic and from 54.3 +/- 1.3 to 62.7 +/- 1.4 mmHg in diastolic blood pressure with dimetophrine, whereas with placebo, systolic blood pressure increased from 80.4 +/- 1.5 to 93.7 +/- 2.9 mmHg and diastolic blood pressure remained unchanged (53.3 +/- 1.4 mmHg). Concomitantly, heart rate decreased significantly with dimetophrine from 88.1 +/- 2.5 to 77.2 +/- 1.4 beats/min, whereas it remained almost unchanged with placebo (from 83.9 +/- 2.5 to 80.0 +/- 1.9 beats/min). The associated symptoms (asthenia, paleness, drowsiness, fatigue, sweating, vertigo and headache) were largely relieved by dimetophrine (70.0% decrease) but not by placebo (37.4%). All symptoms except drowsiness and vertigo were reduced to a significantly larger extent with dimetophrine than with placebo.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adult; Aged; Cardiovascular Agents; Clinical Trials as Topic; Dose-Response Relationship, Drug; Double-Blind Method; Drug Tolerance; Ethanolamines; Female; Heart Rate; Humans; Hypotension; Male; Middle Aged; Random Allocation; Time Factors

Hypotension is of particular relevance for patients with heart failure (HF), since almost all HF drugs cause lowering of blood pressure (BP) and it is associated with a poor prognosis. We aimed to investigate hypotension incidence and risk factors in patients with incident HF in the UK.. Retrospective cohort study including nested case-control analyses.. The Health Improvement Network UK primary care database.. 18 677 adult patients with incident HF during 2000-2005 were followed and cases of hypotension (systolic BP ≤90 mm Hg) were identified. Controls were age-matched, sex-matched and date-matched to cases (1:2).. We estimated hypotension incidence in the full study population and relevant subgroups (eg, sex and age). Potential risk factors for hypotension overall and for multiple versus single hypotensive episodes were evaluated using conditional logistic regression and unconditional regression models, respectively.. During a mean follow-up of 3.31 years, 2565 patients (13.7%) developed hypotension. The incidence of hypotension was 3.17 cases per 100 patient years (95% confidence interval (CI): 3.05-3.30), and was markedly increased in women aged 18-39 years (n=32; 17.72 cases per 100 patient-years; 95% CI: 9.69-29.73). Hypotension risk factors included high healthcare utilisation (proxy measure for HF severity and general comorbidity; eg, ≥10 primary care physician visits versus none, odds ratio (OR): 2.29; 95% CI: 1.34-3.90), previous hypotensive episodes (OR: 2.32; 95% CI: 1.84-2.92), renal failure and use of aldosterone antagonists, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Risk factors identified for hypotension generally overlapped with those for multiple versus single hypotensive episodes.. Hypotension occurs frequently in patients with incident HF. Our findings may help identify patients most likely to benefit from close BP monitoring. The increased incidence of hypotension in young women with HF requires investigation.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Case-Control Studies; Comorbidity; Databases, Factual; Female; General Practice; Heart Failure; Humans; Hypotension; Incidence; Male; Middle Aged; Retrospective Studies; Risk Factors; United Kingdom; Young Adult

Cardiac air embolism should be suspected in any neonate with acute unexplained cardiovascular collapse or worsening oxygenation. We present here five cases that presented with the above symptoms. A comprehensive evaluation including targeted neonatal echocardiography and near-infrared spectroscopy helped confirm the diagnosis and assess the hemodynamic state. Management was supportive including left lateral positioning, chest compressions, and cardiovascular medications to treat pulmonary hypertension and systemic hypotension.

Topics: Cardiovascular Agents; Echocardiography; Embolism, Air; Female; Hemodynamics; Humans; Hypertension, Pulmonary; Hypotension; Infant, Newborn; Male; Patient Positioning; Respiratory Therapy; Spectroscopy, Near-Infrared

Patients hospitalized for first acute coronary syndrome (ACS) are frequently discharged on multiple new medications. The short-term tolerability of these medications is unknown.. This single-center cohort study assessed 30-day health-care utilization and how it may be impacted by medication prescribing trends. We included Olmsted County patients presenting with ACS and previously undiagnosed coronary artery disease in 2008 to 2009. All health-care contacts were reviewed 30 days after index hospital discharge for potential adverse medication effects including documented hypotension or bradycardia, or symptoms likely attributed to the medications.. The study included 86 patients; their mean age was 63 (standard deviation: 15.5 years). Antianginal or antihypertensive cardiovascular (CV) medications were prescribed to 98% of patients at discharge; 76% were prescribed 2 or more. There were 233 health-care contacts in 30 days; 90 (39%) of these contacts were unscheduled. More CV medications tended to be prescribed to patients with unscheduled contacts, both pre-ACS ( P = .045) and upon hospital discharge ( P = .051). Hypotension and/or bradycardia at follow-up occurred in 52 patients (60%). Surprisingly, there was no association between hypotension and/or bradycardia at follow-up and increased health-care utilization ( P = .12). Potential adverse drug effects were reported in 34 (40%) patients. These patients had significantly more total health-care contacts ( P < .001) and unscheduled health-care contacts (median 0 vs 1.5; P < .001).. Symptoms of adverse drug effects were associated with more frequent health-care utilization after ACS. Clinicians need to consider this while striving to increase patient compliance with post-ACS medications and optimize care transitions.

Topics: Acute Coronary Syndrome; Aged; Appointments and Schedules; Bradycardia; Cardiovascular Agents; Drug Prescriptions; Drug-Related Side Effects and Adverse Reactions; Emergency Service, Hospital; Female; Health Resources; Humans; Hypotension; Male; Middle Aged; Minnesota; Office Visits; Patient Discharge; Patient Readmission; Polypharmacy; Practice Patterns, Physicians'; Time Factors

To determine whether a moderate-to-large patent ductus arteriosus (PDA) is responsible for vasopressor-dependent hypotension, occurring at the end of the first postnatal week.. As expected, the incidence of moderate-to-large PDA at the end of the first week differed significantly between epochs (PINDO = 8%; conservative = 64%). In multivariate analyses, infants in the PINDO epoch had a significantly lower incidence of vasopressor-dependent hypotension (11%) than infants in the conservative epoch (21%; OR = 0.40, 95% CI 0.20-0.82). Infants in the PINDO epoch also required less mean airway pressure, had a lower respiratory severity score, and lower mode of ventilation score than infants in the conservative epoch during postnatal days 4-7. The effects of PINDO on both the incidence of vasopressor-dependent hypotension and the need for respiratory support were no longer significant when analyses were adjusted for "presence or absence of a moderate-to-large PDA.". PINDO decreases vasopressor-dependent hypotension and the need for respiratory support at the end of the first postnatal week. These effects are mediated by closure of the PDA.

Topics: Cardiovascular Agents; Cohort Studies; Dopamine; Ductus Arteriosus, Patent; Echocardiography; Female; Humans; Hypotension; Incidence; Indomethacin; Infant, Extremely Premature; Infant, Newborn; Male; Retrospective Studies

Hypotensive states that require fast stabilisation of blood pressure can occur during anaesthesia. In 1963, the 20:1 mixture of cafedrine/theodrenaline (Akrinor) was introduced in Germany for use in anaesthesia and emergency medicine in the first-line management of hypotensive states. Though on the market for many years, few pharmacodynamic data are available on this combination net beta-mimetic agent.. This study aimed to examine the drug combination in real-life clinical practice and recorded time to 10 % mean arterial blood pressure (MAP) increase and heart rate. Furthermore, potential factors that influence drug effectiveness under anaesthesia were assessed.. Data were collected within a standardised anaesthesia protocol. A total of 353 consecutive patients (female/male = 149/204) who received cafedrine/theodrenaline after a drop in MAP ≥ 5% were included in the study. The time to 10 % increase in MAP, dosage of cafedrine/theodrenaline, volume loading, blood pressure and heart rate were monitored over time.. Patients were a mean (standard deviation) of 64.4 ± 15.1 years old with a baseline MAP of 82 ± 14 mmHg, which dropped to a mean of 63 ± 10 mmHg during anaesthesia without gender differences. Cafedrine/theodrenaline (1.27 ± 1.0 mg/kg; 64 ± 50 µg/kg) significantly increased MAP (p < 0.001) by 11 ± 16 mmHg within 5 min, reaching peak values within 17.4 ± 9.0 min. Heart rate was not affected in a clinically significant manner. Cafedrine/theodrenaline induced a 10% MAP increase after 7.2 ± 4.6 min (women) and after 8.6 ± 6.3 min (men) (p = 0.018). Independent of gender, the dose of cafedrine/theodrenaline required to achieve the observed MAP increase of 14 ± 16 mmHg at 15 min was significantly different in patients with heart failure [1.78 ± 1.67 mg/kg (cafedrine)/89.0 ± 83.5 µg/kg (theodrenaline)] compared with healthy patients [1.16 ± 0.77 mg/kg (cafedrine)/58.0 ± 38.5 µg/kg (theodrenaline)] (p = 0.005). Concomitant medication with beta-blocking agents significantly prolonged the time to 10 % MAP increase [9.0 ± 7.0 vs. 7.3 ± 4.3 min (p = 0.008)].. Cafedrine/theodrenaline quickly restores MAP during anaesthesia. Female gender is associated with higher effectiveness, while heart failure and beta-blocker administration lower the anti-hypotonic effect. Prospective studies in defined patient populations are warranted to further characterise the effect of cafedrine/theodrenaline.

Topics: Adrenergic beta-Antagonists; Adult; Aged; Anesthesia; Blood Pressure; Cardiovascular Agents; Drug Combinations; Drug Interactions; Female; Heart Failure; Heart Rate; Humans; Hypotension; Intraoperative Care; Kaplan-Meier Estimate; Male; Middle Aged; Retrospective Studies; Sex Characteristics; Theophylline

Utilization of ultrasound in the evaluation of patients with undifferentiated hypotension has been proposed in several protocols. We sought to assess the impact of an ultrasound hypotension protocol on physicians' diagnostic certainty, diagnostic ability, and treatment and resource utilization.. Prospective observational study.. Emergency department in a single, academic tertiary care hospital.. A convenience sample of patients with a systolic blood pressure less than 90 mm Hg after an initial fluid resuscitation, who lacked an obvious source of hypotension.. An ultrasound-trained physician performed an ultrasound on each patient using a standardized hypotension protocol. Differential diagnosis and management plan was solicited from the treating physician immediately before and after the ultrasound. Blinded chart review was conducted for management and diagnosis during the emergency department and inpatient hospital stay.. The primary endpoints were the identification of an accurate cause for hypotension and change in physicians' diagnostic uncertainty. The secondary endpoints were changes in treatment plan, use of resources, and changes in disposition after performing the ultrasound. One hundred eighteen patients with a mean age of 62 years were enrolled. There was a significant 27.7% decrease in the mean aggregate complexity of diagnostic uncertainty before and after the ultrasound hypotension protocol (1.85-1.34; -0.51 [95% CI, -0.41 to -0.62]) as well as a significant increase in the absolute proportion of patients with a definitive diagnosis from 0.8% to 12.7%. Overall, the leading diagnosis after the ultrasound hypotension protocol demonstrated excellent concordance with the blinded consensus final diagnosis (Cohen k = 0.80). Twenty-nine patients (24.6%) had a significant change in the use of IV fluids, vasoactive agents, or blood products. There were also significant changes in major diagnostic imaging (30.5%), consultation (13.6%), and emergency department disposition (11.9%).. Clinical management involving the early use of ultrasound in patients with hypotension accurately guides diagnosis, significantly reduces physicians' diagnostic uncertainty, and substantially changes management and resource utilization in the emergency department.

Topics: Aged; Blood Pressure; Blood Transfusion; Cardiovascular Agents; Clinical Protocols; Critical Care; Diagnosis, Differential; Emergency Service, Hospital; Female; Fluid Therapy; Humans; Hypotension; Length of Stay; Male; Middle Aged; Point-of-Care Systems; Prospective Studies; Resuscitation; Ultrasonography; Uncertainty

The search for new nitric oxide donors is warranted by the limitations of organic nitrates currently used in cardiology. The new organic nitrate 2-nitrate-1,3-dibuthoxypropan (NDBP) exhibited promising cardiovascular activities in previous studies. The aim of this study was to investigate the cardiorespiratory responses evoked by NDBP and to compare them to the clinically used organic nitrate nitroglycerine (NTG). Arterial pressure, heart rate and respiration were recorded in conscious adult male Wistar rats. Bolus i.v. injection of NDBP (1 to 15mg/kg; n=8) and NTG (0.1 to 5mg/kg; n=8) produced hypotension. NDBP induced bradycardia at all doses, while NTG induced tachycardia at three lower doses but bradycardia at higher doses. Hydroxocobalamin (20mg/kg; HDX), a NO scavenger, blunted hypotension induced by NDBP (15mg/kg), and its bradycardic effect (n=6). In addition, HDX blunted both hypotension and bradycardia induced by a single dose of NTG (2.5mg/kg; n=6). Both NDBP and NTG altered respiratory rate, inducing a biphasic effect with a bradypnea followed by a tachypnea; HDX attenuated these responses. Our data indicate that NDBP and NTG induce hypotension, bradycardia and bradypnea, which are mediated by nitric oxide release.

Topics: Animals; Arterial Pressure; Bradycardia; Cardiovascular Agents; Consciousness; Dose-Response Relationship, Drug; Heart Rate; Hydroxocobalamin; Hypotension; Male; Nitrates; Nitric Oxide; Nitroglycerin; Propane; Rats; Rats, Wistar; Respiration; Tachypnea; Vasodilator Agents

Arginine vasopressin's (AVP) efficacy in the treatment of refractory hypotension is, in part, dependent upon preinfusion endogenous AVP concentration. Corticosteroids, also commonly used to treat refractory hypotension, have been shown to suppress endogenous AVP release. We aimed to determine if corticosteroids affect endogenous AVP concentrations in children recovering from cardiac surgery.. We reviewed the records of children who underwent cardiac surgery between January 2008 and January 2009 and had AVP concentrations available as part of a prior prospective study. Doses of hydrocortisone, methylprednisolone, and dexamethasone administered within the first 48 hours after cardiopulmonary bypass were quantitated. Multivariable linear regression was performed to determine if corticosteroids had a significant effect on 48-hour plasma AVP concentration.. Sixty-nine children with plasma AVP concentrations available were reviewed, 34 (49%) of which received corticosteroids within 48 hours after cardiopulmonary bypass. On multivariable regression, greater number of corticosteroid doses but not cumulative corticosteroid dosage was significantly associated with low 48-hour AVP concentration (β=-4.0; 95% confidence intervals, -6.5 to -1.4).. Children who receive multiple doses of corticosteroids after cardiac surgery, regardless of potency, are likely to have low endogenous AVP concentrations. Children who remain unstable despite corticosteroids may respond favorably to exogenous AVP therapy.

Topics: Adrenal Cortex Hormones; Arginine Vasopressin; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Cardiovascular Agents; Child; Child, Preschool; Dexamethasone; Female; Glucocorticoids; Humans; Hydrocortisone; Hypotension; Infant; Male; Methylprednisolone; Prospective Studies; Regression Analysis; Vasoconstrictor Agents

The timing of ventricular assist device (VAD) implantation is always a matter of debate, especially when a patient is referred from a non-VAD institute. We focused on objective noninvasive parameters at the time of admission to a VAD implant center and analyzed the factors predicting the necessity of early VAD. METHODS AND RESULTS: We retrospectively analyzed advanced heart failure (HF) patients referred since January 2011, including patients less than 65 years old. They all had a history of hospitalization for HF management in non-VAD institutes within 1 month before referral. We excluded patients transferred with mechanical circulatory support. We enrolled 46 patients (40 males, 39.8±13.4 years old). Among them, 26 patients had a VAD implanted or died within 120 days. By multivariable logistic analysis using admission parameters, systolic blood pressure (BP) <93 mmHg [odds ratio (OR) 13.335], hemoglobin <12.7 g/dl (OR 12.175) and serum total cholesterol <144 mg/dl (OR 8.096) were significant predictors of early VAD requirement. We constructed a scoring system according to the ORs, and the area under the receiver-operating characteristic curve was 0.913.. Low BP, low serum cholesterol and anemia on admission predict early VAD in advanced HF patients who have been treated in non-VAD institutes. Such patients should be promptly referred to a VAD implant center.

Topics: Adult; Anemia; Anthropometry; Area Under Curve; Cardiovascular Agents; Cholesterol; Combined Modality Therapy; Comorbidity; Female; Heart Failure; Heart-Assist Devices; Humans; Hypotension; Japan; Kaplan-Meier Estimate; Male; Middle Aged; Patient Selection; Referral and Consultation; Retrospective Studies; Risk Assessment; ROC Curve; Severity of Illness Index; Time Factors

Topics: Acute Coronary Syndrome; Aged, 80 and over; Aortic Diseases; Atherosclerosis; Calcinosis; Cardiovascular Agents; Colitis, Ischemic; Dietary Supplements; Humans; Hyperparathyroidism, Secondary; Hypertension; Hypotension; Kidney Failure, Chronic; Male; Myocardial Ischemia; Nephrosclerosis; Obesity; Parenteral Nutrition; Pneumatosis Cystoides Intestinalis; Renal Dialysis; Splanchnic Circulation

Haemodynamic changes that occur during pregnancy are maximal between 28 and 34 weeks. In the pregnant woman with several associated diseases, such as hypertensive myocardiopathy and pre-gestational diabetes, these changes can lead to a difficult control of pulmonary hypertension and acute pulmonary oedema. We report the case of a pregnant woman with long term type 1 diabetes mellitus who suffered pre-eclampsia in a previous pregnancy, and since then developed hypertensive cardiomyopathy. She was admitted at 30 week gestation for metabolic and blood pressure control, and developed congestive cardiac failure after the administration of betamethasone for foetal lung maturity. A transthoracic echocardiogram showed a non-dilated hypertrophic left ventricle with good systolic function, restrictive diastolic dysfunction and moderate pulmonary arterial hypertension. When her general condition improved, we performed a caesarean section under regional anaesthesia to prevent the complications of pulmonary and systemic hypertension. We present the anaesthetic management and resolution of complications after oxytocin administration.

Topics: Adult; Anesthesia, Epidural; Anesthesia, Obstetrical; Betamethasone; Cardiomyopathy, Hypertrophic; Cardiovascular Agents; Cesarean Section, Repeat; Diabetes Mellitus, Type 1; Diastole; Female; Heart Failure; Humans; Hypertension, Pulmonary; Hypotension; Infant, Newborn; Intraoperative Complications; Norepinephrine; Oxytocin; Phenylephrine; Pre-Eclampsia; Preanesthetic Medication; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy in Diabetics; Supine Position

The assessment of baroreflex function since the first appearance of endotoxemia is important because the arterial baroreflex should exert a protective role during sepsis. Nevertheless, contrasting results were previously reported. This could be due to the hemodynamic instability characterizing this condition that may per se interfere with reflex cardiovascular adjustments. The aim of our study was therefore to study the baroreflex function (a) since the very beginning of infusion of Escherichia coli lipopolysaccharide (LPS) toxin and (b) in absence of the unloading effect produced by a decrease in blood pressure. Lipopolysaccharide was infused in 10 rats for 20 min at the infusion rate of 0.05 mg · kg · min. Blood pressure was continuously measured before, during, and after infusion, and the baroreflex function was evaluated analyzing spontaneous fluctuations of systolic blood pressure and pulse interval by the sequence and transfer-function techniques. Plasma concentrations of inflammatory (interleukin 6, tumor necrosis factor α) and anti-inflammatory (interleukin 10) cytokines were measured in other eight rats, similarly instrumented, four of which receiving the same LPS infusion. We found that blood pressure levels did not change with the infusion of LPS, whereas inflammatory cytokines increased significantly. The baroreflex sensitivity was significantly reduced 10 min after the beginning of LPS infusion, reached values about half those at baseline within 15 min after the start of infusion, and remained significantly low after the end of infusion. In conclusion, we documented that septic shock inducing LPS infusion is responsible for a very rapid impairment of the baroreflex function, independent from the level of blood pressure.

Topics: Administration, Intravenous; Animals; Baroreflex; Blood Pressure; Cardiovascular Agents; Cytokines; Endotoxemia; Escherichia coli; Hypotension; Lipopolysaccharides; Rats; Rats, Sprague-Dawley

The objective of this study was to determine the effects of a TREM (triggering receptor expressed on myeloid cells 1)-like transcript 1-derived peptide (LR12) administration during septic shock in pigs. Two hours after induction of a fecal peritonitis, anesthetized and mechanically ventilated adult male minipigs were randomized to receive LR12 (n = 6) or its vehicle alone (normal saline, n = 5). Two animals were operated and instrumented without the induction of peritonitis and served as controls (sham). Resuscitation was achieved using hydroxyethyl starch (up to 20 mL/kg) and norepinephrine infusion (up to 10 μg/kg per minute). Hemodynamic parameters were continuously recorded. Gas exchange, acid-base status, organ function, and plasma cytokines concentrations were evaluated at regular intervals until 24 h after the onset of peritonitis when animals were killed under anesthesia. Peritonitis induced profound hypotension, myocardial dysfunction, lactic acidosis, coagulation abnormalities, and multiple organ failure. These disorders were largely attenuated by LR12. In particular, cardiovascular failure was dampened as attested by a better mean arterial pressure, cardiac index, cardiac power index, and S(v)O(2), despite lower norepinephrine requirements. LR12, a TREM-like transcript 1-derived peptide, exhibits salutary properties during septic shock in adult minipigs.

Topics: Animals; Blood Coagulation Disorders; Cardiovascular Agents; Cardiovascular Diseases; Hemodynamics; Hydroxyethyl Starch Derivatives; Hypotension; Male; Multiple Organ Failure; Random Allocation; Receptors, Immunologic; Shock, Septic; Swine; Swine, Miniature

'Sudden collapse' following envenoming by some Australasian elapids is a poorly understood cause of mortality. We have previously shown that Oxyuranus scutellatus venom causes cardiovascular collapse in anaesthetized rats. Prior administration of a sub lethal dose of venom attenuated the response to subsequent administration of higher (lethal) venom doses. In this study, we investigated the possible mechanisms mediating this 'protective effect'. Papuan taipan venom (5μg/kg, i.v.) produced a small transient hypotension in anaesthetized rats, while 10μg/kg resulted in a 73±12% decrease in arterial pressure. Venom (20μg/kg or 50μg/kg) produced cardiovascular collapse in all animals tested (n=12). Cardiovascular collapse by 50μg/kg venom was prevented by prior administration of 'priming' doses of venom (5, 10 and 20μg/kg). Also, prior administration of indomethacin (30mg/kg, i.v.) or heparin (300units/kg, i.v.) prevented sudden collapse induced by venom (20μg/kg). Venom was without effect in isolated hearts indicating that a direct cardiac effect was unlikely to be responsible for 'sudden collapse'. Venom induced endothelium-dependent and -independent relaxation in pre-contracted rat mesenteric artery rings which was inhibited by indomethacin, IbTx and Rp-8-CPT-cAMPs. This relaxation was markedly reduced upon second exposure. Our results indicate that cardiovascular collapse induced by O. scutellatus venom may be due to a combination of release of dilator autacoids and to direct relaxation of vascular smooth muscle involving the cAMP/protein kinase A cascade. Further work will involve identification of the venom component(s) responsible for this action and may provide insight into the management of envenomed patients.

Topics: Animals; Australasia; Cardiovascular Agents; Cardiovascular System; Elapid Venoms; Hypotension; In Vitro Techniques; Indomethacin; Male; Mesenteric Arteries; Muscle Contraction; Rats; Rats, Sprague-Dawley

Topics: Anti-Bacterial Agents; Bacteremia; Borrelia; Cardiopulmonary Resuscitation; Cardiovascular Agents; Ceftriaxone; Child; Combined Modality Therapy; Cytokines; Doxycycline; Endotoxins; Female; Humans; Hypotension; Positive-Pressure Respiration; Pulmonary Edema; Relapsing Fever; Shock, Cardiogenic; Tachycardia; Unconsciousness

This observational study investigated which of the three most common definitions of intraoperative hypotension (IOH), reported in a published systematic literature review, were associated best with anaesthetists' administration of antihypo tensive medication (AHM). IOH and AHM use in anaesthetic procedures in a mixed surgical population (n = 2350) were also reviewed. The definitions were: arterial systolic blood pressure (SBP) < 100 mmHg or a fall in SBP of > 30% of the preoperative SBP baseline; arterial SBP < 80 mmHg; a fall in SBP of > 20% of the preoperative SBP. Accuracy of predicting AHM using these three definitions was 67%, 54% and 65%, respectively. Prediction by a new fourth definition, using an optimal threshold of minimal SBP falling to < 92 mmHg or by > 24% of preoperative baseline, was 68% accurate. In multivariate logistic analysis, age, volatile versus intravenous anaesthetics, medical history of arterial hypertension and all four definitions of IOH were associated with intraoperative AHM, however IOH was not associated with postoperative in-patient stay. The three original definitions correlated poorly with the anaesthetist's judgement about applying AHM. Anaesthetists make complex decisions regarding the relevance of IOH, considering various perioperative factors in addition to SBP. Age, physical status and duration and type of surgery showed better correlations with postoperative in-patient stay than IOH.

Topics: Cardiovascular Agents; Humans; Hypotension; Intraoperative Period; Monitoring, Physiologic; Retrospective Studies

The diagnosis and management of pericardial disease are very challenging for clinicians. The evidence base in this field is relatively scarce compared with other disease entities in cardiology. In this article, we outline a unified, stepwise pathway-based approach for the management of pericardial disease. We used the "CHASER" acronym to define the entry points into the pathway. These include chest pain, hypotension or arrest, shortness of breath, echocardiographic or other imaging finding of pericardial effusion, and right-predominant heart failure. We propose a score for the assessment of pericardial effusion that is composed of the following 3 parameters: the etiology of the effusion, the size of the effusion, and the echocardiographic assessment of hemodynamic parameters. The score is applied to clinically stable patients with pericardial effusion to quantify the necessity of pericardial effusion drainage. A stepwise, pathway-based approach to the management of pericardial disease is intended to provide guidance for clinicians in decision-making and a patient-tailored evidence-based approach to medical and surgical therapy for pericardial disease. The pathway for the management of pericardial disease is the ninth project to be incorporated into the "Advanced Cardiac Admission Program" at Saint Luke's Roosevelt Hospital Center of Columbia University in New York. Further studies should focus on the validation of the feasibility, efficacy, and reliability of this pathway.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Cardiac Tamponade; Cardiovascular Agents; Chest Pain; Clinical Protocols; Critical Pathways; Disease Management; Echocardiography; Electrocardiography; Evidence-Based Practice; Heart Failure; Hemodynamics; Humans; Hypotension; Pericardial Effusion; Pericardiocentesis; Pericardium; Program Evaluation; Severity of Illness Index

Amniotic fluid embolism (AFE) is a rare, but often catastrophic, complication of pregnancy and associated with severe coagulopathy. We present an algorithm-based approach in managing coagulopathy and hemorrhage in a fatal case of histopathologically proven AFE. Thrombelastometry was used for rapid evaluation of the coagulation status. Stop of extensive hyperfibrinolysis with tranexamic acid, stabilization of initial clot formation with high-dose fibrinogen and platelet transfusions, and use of prothrombin complex concentrate together with a 1: 1 transfusion regimen of red packed cells and fresh frozen plasma was successful to control diffuse bleeding and restore clot firmness after hysterectomy. Stable clotting situation was maintained despite further clinical deterioration and development of multiple organ failure in this patient.

Topics: Acidosis; Adult; Algorithms; Blood Coagulation Factors; Blood Component Transfusion; Cardiovascular Agents; Case Management; Catastrophic Illness; Combined Modality Therapy; Diagnosis, Differential; Drug Therapy, Combination; Embolism, Amniotic Fluid; Fatal Outcome; Female; Fibrinogen; Humans; Hypotension; Hysterectomy; Infant, Newborn; Male; Multiple Organ Failure; Placenta, Retained; Postpartum Hemorrhage; Pregnancy; Sperm Injections, Intracytoplasmic; Thrombelastography; Tranexamic Acid

Babies are frequently exposed to cerebral hypoxia and ischemia (H/I) during the perinatal period as a result of stroke, problems with delivery, or postdelivery respiratory management. The sole approved treatment for acute stroke is tissue type plasminogen activator. H/I impairs pial artery dilation (PAD) induced by hypercapnia and hypotension, the impairment aggravated by type plasminogen activator and attenuated by the plasminogen activator inhibitor-1-derived peptide EEIIMD. Mitogen-activated protein kinase (MAPK), a family of at least three kinases, ERK, p38, and JNK, is upregulated after H/I and ERK contribute to impaired cerebrovasodilation. This study determined the roles of p38 and JNK MAPK in the impairment of dilation post-H/I in pigs equipped with a closed cranial window and the relationship between alterations in MAPK isoforms and EEIIMD-mediated cerebrovascular protection. Cerebrospinal fluid-phosphorylated (activated) p38 MAPK, but not JNK MAPK, was increased after H/I, an effect potentiated by intravenous EEIIMD administered 1 h postinjury. PAD in response to hypercapnia and hypotension was blunted by H/I, but dilation was maintained by EEIIMD. PAD was further impaired by the p38 antagonist SB-203580 but unchanged by the JNK antagonist SP-600125. Isoproterenol-induced PAD was unchanged by H/I, EEIIMD, SB-203580, and SP-600125. These data indicate that postinjury treatment with EEIIMD attenuated impaired cerebrovasodilation post-H/I by upregulating p38 but not JNK. These data suggest that plasminogen activator inhibitor-1-based peptides and other approaches to upregulate p38 may offer a novel approach to increase the benefit-to-risk ratio of thrombolytic therapy for diverse central nervous system disorders associated with H/I.

Topics: Animals; Animals, Newborn; Anthracenes; Blood Pressure; Carbon Dioxide; Cardiovascular Agents; Cerebrovascular Circulation; Disease Models, Animal; Dose-Response Relationship, Drug; Enzyme Activation; Female; Hypercapnia; Hypotension; Hypoxia-Ischemia, Brain; Imidazoles; Injections, Intravenous; Isoproterenol; JNK Mitogen-Activated Protein Kinases; Male; Oligopeptides; p38 Mitogen-Activated Protein Kinases; Phosphorylation; Pia Mater; Protein Kinase Inhibitors; Pyridines; Swine; Time Factors; Up-Regulation; Vasodilation; Vasodilator Agents

Preload parameters in postresuscitation phase are not sufficiently sensitive to guide fluid therapy in critically ill patients. We analyzed modifications in the fluid therapy and vasoactive drugs of critically ill patients that were produced by inclusion of extravascular lung water (EVLW) data in the treatment protocol and evaluated the short-term response.. This observational and prospective study included consecutive patients with hypotension or hypoxemia, comparing the therapeutic plan for fluid and vasoactive drug treatment between before and after knowing the EVLW value.. We studied 42 patients. After knowing the EVLW, 52.4% (n = 22) of initial therapeutic plans were changed, modifying fluid therapy in all of these cases and vasoactive therapy in 22% of them. EVLW value was 13.91 +/- 5.62 in patients with change of therapeutic plan versus 10 +/- 4.52 in those with no change (p < 0.05). No differences were found in preload parameters as a function of change/no change. The most frequent decision change (n = 13) was to fluid reduction plus diuretic administration, and patients with this modification had significantly (p < 0.05) higher EVLW values compared with the remaining patients with a change in fluid therapy. Out of the 22 patients with a modified therapeutic decision, the therapy proved effective in 18 patients. Quantification of EVLW in patients who can be considered euvolemic induces important modifications in fluid and vasoactive therapy. These changes generally resulted in a lower volume loading and a positive outcome for the patient.

Topics: Analysis of Variance; Cardiovascular Agents; Chi-Square Distribution; Critical Illness; Extravascular Lung Water; Female; Fluid Therapy; Hemodynamics; Humans; Hypotension; Hypoxia; Indicator Dilution Techniques; Male; Prospective Studies; Respiration, Artificial; Respiratory Distress Syndrome; Sepsis

Heart failure (HF) represents a major public health issue in an aging population. Although HF is a leading cause of morbidity and mortality in developed countries, the clinical features of HF in Japan remain unclear.. This observational cohort study analyzed data from the Heart Institute of Japan--Department of Cardiology (HIJC)-HF Registry, which is based on a nationwide survey by the HIJC, Tokyo Women's Medical University and its affiliated hospitals. Of 3,578 consecutive patients (average age, 69.8 years; females 40.7%) hospitalized for HF between January 2001 and December 2002, 95.0% were followed up until the end of 2005 (median, 2.8 years). The 1- and 3-year mortality rates were 11.3% and 29.2%, respectively. Multivariate analysis revealed that advanced age (hazard ratio 1.71 [95% confidence interval 1.38-2.12]; p<0.001), symptomatic HF at hospital discharge (3.76 [2.30-6.17]; p<0.001), renal impairment (1.96 [1.50-2.57]; p=0.008), anemia (1.46 [1.18-1.80]; p=0.02) and low pulse pressure (2.88 [1.62-5.13]; p=0.0003) were significantly associated with total death.. Although the long-term mortality rate for Japanese patients with HF is lower than in other countries, several markers are modifiable. The data demonstrate that continued improvements in the treatment of Japanese patients with HF are still needed.

Topics: Age Factors; Aged; Aged, 80 and over; Anemia; Cardiovascular Agents; Female; Health Care Surveys; Heart Failure; Humans; Hypotension; Inpatients; Japan; Kaplan-Meier Estimate; Kidney Diseases; Male; Middle Aged; Multivariate Analysis; Proportional Hazards Models; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome

To determine whether outcomes of tilt-table tests improved after withdrawal of fall-risk-increasing drugs (FRIDs).. Prospective cohort study.. Geriatric outpatient clinic.. Two hundred eleven new, consecutive outpatients, recruited from April 2003 until December 2004.. Tilt-table testing was performed on all participants at baseline. Subsequently, FRIDs were withdrawn in all fallers in whom it was safely possible. At a mean follow-up of 6.7 months, tilt-table testing was repeated in 137 participants. Tilt-table testing addressed carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), and vasovagal collapse (VVC). Odds ratios (ORs) of tilt-table-test normalization according to withdrawal (discontinuation or dose reduction) of FRIDs were calculated using multivariate logistic regression analysis.. After adjustment for confounders, the reduction of abnormal test outcomes (ORs) according to overall FRID withdrawal was 0.34 (95% confidence interval (CI)=0.06-1.86) for CSH, 0.35 (95% CI=0.13-0.99) for OH, and 0.27 (95% CI=0.02-3.31) for VVC. For the subgroup of cardiovascular FRIDs, the adjusted OR was 0.13 (95% CI=0.03-0.59) for CSH, 0.44 (95% CI=0.18-1.0) for OH, and 0.21 (95% CI=0.03-1.51) for VVC.. OH improved significantly after withdrawal of FRIDs. Subgroup analysis of cardiovascular FRID withdrawal showed a significant reduction in OH and CSH. These results imply that FRID withdrawal can cause substantial improvement in cardiovascular homeostasis. Derangement of cardiovascular homeostasis may be an important mechanism by which FRID use results in falls.

Topics: Accidental Falls; Aged; Cardiovascular Agents; Carotid Sinus; Female; Humans; Hypotension; Hypotension, Orthostatic; Male; Mobility Limitation; Psychotropic Drugs; Risk Factors; Syncope; Syncope, Vasovagal; Tilt-Table Test

Few data exist on gender-related differences in clinical presentation, diagnostic findings, management, and outcomes in acute aortic dissection (AAD).. Accordingly, we evaluated 1078 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) to assess differences in clinical features, management, and in-hospital outcomes between men and women. Of the patients enrolled in IRAD (32.1%) with AAD, 346 were women. Although less frequently affected by AAD (32.1% of AAD), women were significantly older and had more often presented later than men (P=0.008); symptoms of coma/altered mental status were more common, whereas pulse deficit was less common. Diagnostic imaging suggestive of rupture, ie, periaortic hematoma, and pleural or pericardial effusion were more commonly observed in women. In-hospital complications of hypotension and tamponade occurred with greater frequency in women, resulting in higher in-hospital mortality compared with men. After adjustment for age and hypertension, women with aortic dissection die more frequently than men (OR, 1.4, P=0.04), predominantly in the 66- to 75-year age group. Moreover, surgical outcome was worse in women than men (P=0.013); type A dissection in women was associated with a higher surgical mortality of 32% versus 22% in men despite similar delay, surgical technique, and hemodynamics.. Our analysis provides insights into gender-related differences in AAD with regard to clinical characteristics, management, and outcomes; important diagnostic and therapeutic implications may help shed light on aortic dissection in women to improve their outcomes.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Aortic Aneurysm; Aortic Dissection; Cardiac Tamponade; Cardiovascular Agents; Case Management; Combined Modality Therapy; Consciousness Disorders; Europe; Female; Hospital Mortality; Humans; Hypotension; Life Tables; Male; Middle Aged; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Registries; Retrospective Studies; Risk Factors; Sex Factors; Survival Analysis; Treatment Outcome; United States

Topics: Arrhythmias, Cardiac; Cardiovascular Agents; Diazepam; Drug Overdose; Female; Humans; Hydroxychloroquine; Hypokalemia; Hypotension

Topics: Aged; Atrial Fibrillation; Carcinoma, Squamous Cell; Cardiovascular Agents; Chylothorax; Combined Modality Therapy; Drainage; Hemodynamics; Humans; Hypotension; Laryngeal Neoplasms; Laryngectomy; Male; Neck Dissection; Parenteral Nutrition; Pleural Effusion; Postoperative Complications

Recently, we showed that intravenous (i.v.) treatment with the essential oil of Mentha x villosa (EOMV) in pentobarbitone-anaesthetised rats decreased blood pressure; the effect occurred independently of the presence of an operational central autonomic drive to the cardiovascular system. This finding suggested that the hypotensive activity of EOMV may result from its vasodilatory effects directly upon vascular smooth muscle. The present study examines this possibility and whether EOMV-induced hypotension is mediated, at least in part, by an endothelial L-arginine/nitric oxide pathway. In conscious rats, i.v. injections of bolus doses (1 to 20 mg/kg) of EOMV elicited immediate and dose-dependent decreases in mean aortic pressure (MAP) and heart rate (HR). Pretreatment with i.v. hexamethonium (30 mg/kg) reduced the EOMV-induced bradycardia without affecting the hypotension. However, i.v. pretreatment with the nitric oxide synthase inhibitor, N(G)-nitro-L-arginine methyl (L-NAME, 20 mg/kg), reduced partially, but significantly, the maximal percent decreases in MAP elicited by EOMV without affecting the bradycardia. In rat isolated thoracic aorta preparations, EOMV (1 - 130 microg/ml) induced a concentration-dependent reduction of potassium (60 mM)-induced contraction. This smooth muscle-relaxant activity of EOMV was significantly reduced by the incubation of endothelium-intact rings with L-NAME (20 microM), as evidenced by the significant enhancement in the IC50 for EOMV-induced reduction of potassium-induced contraction (133.8 +/- 26.5 vs. 65.2 +/- 8.2 microg/ml in the absence of L-NAME). Furthermore, the vasorelaxant effects of EOMV in endothelium-denuded aortic rings were also significantly reduced (IC50 = 109 +/- 10 microg/ml), compared to those observed in segments with intact endothelium (IC50 = 61 +/- 13 microg/ml). These results show that i.v. treatment with EOMV dose-dependently decreases blood pressure in conscious rats, and that this action is due to an active vascular relaxation rather than withdrawal of sympathetic tone. Released nitric oxide from vascular endothelial cells appears partially involved in the aortic relaxation induced by EOMV and in turn in the mediation of EOMV-induced hypotension. They further support the concept that EOMV-induced hypotension and bradycardia occurred independently.

Topics: Animals; Aorta, Thoracic; Blood Pressure; Cardiovascular Agents; Consciousness; Dose-Response Relationship, Drug; Endothelium, Vascular; Hypotension; In Vitro Techniques; Male; Mentha; Nitric Oxide; Oils, Volatile; Plants, Medicinal; Rats; Rats, Wistar; Signal Transduction; Vasoconstriction

The cardiovascular effects of tetrahydroaminoacridine (tacrine; THA) were investigated in haemorrhaged rats. Intracerebroventricular (i.c.v.) injection of THA (10, 25 and 50 microg) restored blood pressure in a dose- and time-dependent manner. Atropine (10 microg, i.c.v.), a muscarinic receptor antagonist, attenuated the pressor response to THA (25 microg, i.c.v.), while mecamylamine (50 microg, i.c.v.), a nicotinic receptor antagonist, caused only a slight blockade in the pressor effect of THA. Simultaneous pretreatment with atropine and mecamylamine almost abolished the blood pressure effect of i.c.v. THA (25 microg). Haemorrhage increased plasma levels of adrenaline, noradrenaline, vasopressin and plasma renin activity. THA (25 microg, i.c.v.) administration caused additional increases in vasopressin and adrenaline levels but not of renin activity and noradrenaline levels. The reversal of hypotension by THA was greatly attenuated by administration of either prazosin, an alpha(1)-adrenoceptor antagonist (0.5 mg/kg, i.v.) or by the vasopressin V(1) receptor antagonist [beta-mercapto-beta,beta-cyclopenta-methylenepropionyl(1), O-Me-Tyr(2)-Arg(8)]-vasopressin (10 microg/kg, i.v.). Pretreatment of rats with both prazosin and the vasopressin antagonist simultaneously completely inhibited the pressor response. Intravenous administration of THA (1, 1.5 and 3 mg/kg) also reversed hypotension in rats. Atropine (10 microg, i.c.v.) greatly attenuated the pressor response to THA (1.5 mg/kg, i.v.), while mecamylamine (50 microg, i.c.v.) failed to change the pressor effect of THA. In anaesthetised haemorrhaged rats, THA (1.5 mg/kg, i.v.) increased blood pressure and survival time of the animals. These results show that centrally and peripherally injected THA reverses haemorrhagic hypotension and increases survival time in rats. Activation of central muscarinic and nicotinic receptors is involved in the pressor response to i.c.v. THA. The pressor effect of i.v. THA is solely mediated by central muscarinic receptors. Moreover, the increase in plasma adrenaline and vasopressin levels appears to be involved in the pressor effect of THA.

Topics: Adrenergic alpha-Antagonists; Anesthetics, Intravenous; Animals; Antidiuretic Hormone Receptor Antagonists; Atropine; Blood Pressure; Cardiovascular Agents; Cholinesterase Inhibitors; Dose-Response Relationship, Drug; Epinephrine; Female; Hypotension; Injections, Intravenous; Injections, Intraventricular; Male; Mecamylamine; Norepinephrine; Prazosin; Rats; Rats, Wistar; Renin; Shock, Hemorrhagic; Survival Analysis; Tacrine; Time Factors; Urethane; Vasopressins

Topics: Aged; Cardiac Catheterization; Cardiovascular Agents; Cytochrome P-450 CYP3A; Cytochrome P-450 Enzyme Inhibitors; Diltiazem; Drug Interactions; Erectile Dysfunction; Humans; Hypotension; Male; Mixed Function Oxygenases; Nitrates; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

Topics: Cardiovascular Agents; Cytochrome P-450 CYP3A; Cytochrome P-450 Enzyme Inhibitors; Diltiazem; Drug Interactions; Humans; Hypotension; Mixed Function Oxygenases; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

Cannabinoids, including the endogenous ligand anandamide, elicit pronounced hypotension and bradycardia through the activation of CB1 cannabinoid receptors. A second endogenous cannabinoid, 2-arachidonoyl glycerol (2-AG), has been proposed to be the natural ligand of CB1 receptors. In the present study, we examined the effects of 2-AG on mean arterial pressure and heart rate in anesthetized mice and assessed the role of CB1 receptors through the use of selective cannabinoid receptor antagonists and CB1 receptor knockout (CB1(-/-)) mice. In control ICR mice, intravenous injections of 2-AG or its isomer 1-AG elicit dose-dependent hypotension and moderate tachycardia that are unaffected by the CB1 receptor antagonist SR141716A. The same dose of SR141716A (6 nmol/g IV) completely blocks the hypotensive effect and attenuates the bradycardic effect of anandamide. 2-AG elicits a similar hypotensive effect, resistant to blockade by either SR141716A or the CB2 antagonist SR144528, in both CB1(-/-) mice and their homozygous (CB1(+/+)) control littermates. In ICR mice, arachidonic acid (AA, 15 nmol/g IV) elicits hypotension and tachycardia, and indomethacin (14 nmol/g IV) inhibits the hypotensive effect of both AA and 2-AG. Synthetic 2-AG incubated with mouse blood is rapidly (<2 minutes) and completely degraded with the parallel appearance of AA, whereas anandamide is stable under the same conditions. A metabolically stable ether analogue of 2-AG causes prolonged hypotension and bradycardia in ICR mice, and both effects are completely blocked by SR141716A, whereas the same dose of 2-AG-ether does not influence blood pressure and heart rate in CB1(-/-) mice. These findings are interpreted to indicate that exogenous 2-AG is rapidly degraded in mouse blood, probably by a lipase, which masks its ability to interact with CB1 receptors. Although the observed cardiovascular effects of 2-AG probably are produced by an arachidonate metabolite through a noncannabinoid mechanism, the CB1 receptor-mediated cardiovascular effects of a stable analogue of 2-AG leaves open the possibility that endogenous 2-AG may elicit cardiovascular effects through CB1 receptors.

Topics: Anesthesia; Animals; Arachidonic Acids; Blood Pressure; Camphanes; Cardiovascular Agents; Cardiovascular Diseases; Dose-Response Relationship, Drug; Endocannabinoids; Female; Glycerides; Heart Rate; Hypotension; Indomethacin; Ligands; Male; Mice; Mice, Inbred ICR; Mice, Knockout; Piperidines; Pyrazoles; Receptors, Cannabinoid; Receptors, Drug; Rimonabant; Tachycardia

Topics: Adult; Anuria; Bradycardia; Cardiovascular Agents; Cold Temperature; Coma; Combined Modality Therapy; Drug Overdose; Electric Countershock; Emergencies; Extracorporeal Membrane Oxygenation; Female; Frostbite; Humans; Hypotension; Hypothermia; Intermittent Positive-Pressure Ventilation; Psychotropic Drugs; Resuscitation; Suicide, Attempted; Ventricular Fibrillation

Cholestasis depresses cardiovascular function and responsiveness. In a previous study, the 3-day bile duct manipulated (BDM) rat was validated as the appropriate control for studying in vitro vascular neuroeffector mechanisms in cholestasis. The present study reports the findings on the effect of BDM on cardiovascular function and responsiveness in conscious rats. Cardiovascular responsiveness was assessed by measuring the in vivo pressor responses to a 90 degrees head-up vertical tilt, a controlled hemorrhage, and to intravenously infused norepinephrine, tyramine, the indirectly acting sympathomimetic drug, isoproterenol, the nonselective beta-adrenoceptor agonist, angiotensin I, and angiotensin II. The concentrations of catecholamines and plasma renin activity measured in plasma samples obtained from conscious chronically arterial catheterized BDM rats were compared to identical data obtained from rats in which the bile duct was not manipulated. There were no differences in cardiovascular responsiveness to any of these procedures or drug infusions between the two groups of rats. Plasma catecholamine concentrations and renin activities in the BDM rats were not significantly different from control rats. Although no differences in cardiovascular responsiveness between BDM and control rats were observed, these data confirm the choice of the BDM as the control group for experiments assessing the effects of cholestasis on cardiovascular responsiveness.

Topics: Animals; Bile Ducts; Blood Loss, Surgical; Blood Pressure; Cardiovascular Agents; Cardiovascular System; Hypotension; Infusions, Intravenous; Male; Rats; Rats, Sprague-Dawley

Topics: Age Factors; Aged; Bradycardia; Cardiac Pacing, Artificial; Cardiovascular Agents; Carotid Sinus; Heart Rate; Humans; Hypotension; Myocardial Contraction; Neurotransmitter Agents; Pacemaker, Artificial; Pressoreceptors; Sympathetic Nervous System; Syncope, Vasovagal; Terminology as Topic; Tilt-Table Test; Vagus Nerve; Vasomotor System; Ventricular Function

To present baseline data from a prospective study of postprandial hypotension in 499 elderly persons in a long-term health care facility.. Analyses of baseline data for a prospective study.. A large long-term health care facility where 499 ambulatory or wheelchair-bound residents were studied.. The 499 residents were > or = 62 years of age, mean age 80 +/- 9 years (range 62-100), 71% female, 29% male, 66% white, 27% black, 7% Hispanic, 68% ambulatory, and 32% wheelchair-bound.. The mean maximal decrease in postprandial systolic and diastolic blood pressures was 15 +/- 6 mm Hg/6 +/- 2 mm Hg. The mean maximal decrease in postprandial systolic blood pressure occurred 15 minutes after eating in 13% of residents, 30 minutes after eating in 20% of residents, 45 minutes after eating in 26% of residents, 60 minutes after eating in 30% of residents, and 75 minutes after eating in 11% of residents. Of 499 residents, 118 (24%) had a maximal decrease in postprandial systolic blood pressure of > or = 20 mm Hg. The mean maximal decrease in postprandial systolic blood pressure was 24 +/- 5 mm Hg in residents with syncope in the prior 6 months and 14 +/- 5 mm Hg in residents without syncope (P < 0.0001). The mean maximal decrease in postprandial systolic blood pressure was 21 +/- 5 mm Hg in residents with falls in the preceding 6 months and 13 +/- 4 mm Hg in residents without falls (P < 0.0001). The mean maximal decrease in postprandial systolic blood pressure was significantly greater in residents treated with angiotensin-converting enzyme inhibitors, calcium channel blockers, diuretics, nitrates, digoxin, and psychotropic drugs than in residents not treated with these drugs. The mean maximal decrease in postprandial systolic and diastolic blood pressures was not significantly different in elderly blacks, Hispanics, and whites.. A more severe reduction in postprandial systolic blood pressure correlates with a history of syncope or falls in the previous 6 months. Long-term follow-up is being planned to determine whether a marked reduction in postprandial systolic blood pressure in elderly persons correlates with a higher incidence of falls, syncope, new coronary events, new stroke, and total mortality.

Topics: Accidental Falls; Aged; Aged, 80 and over; Blood Pressure; Cardiovascular Agents; Eating; Female; Humans; Hypotension; Long-Term Care; Male; Middle Aged; Nursing Homes; Prospective Studies; Psychotropic Drugs; Syncope

Over the past six years there has been a 15-fold increase in the number of patients requiring reoperation coronary artery bypass grafting (RCABG) surgery at the University of Alabama in Birmingham. To determine the perioperative risk, a retrospective chart survey of one calendar year's (1981) experience was made comparing the 58 RCABG patients with 59 cohorts undergoing primary operation. All patients were anaesthetized with diazepam, fentanyl and halothane or enflurane anaesthesia. Preoperative evaluation revealed by history that the incidence of unstable angina and digoxin use were greater (p = 0.05) in the RCABG patients. Cardiac catheterization revealed a higher incidence (26 vs 89 percent) of left main coronary disease in controls and similar indices of left ventricular function (wall abnormalities, ejection fraction and LVEDP). Operating and bypass times were longer (p less than 0.01) for RCABG patients and there was a trend for greater (p = 0.08) use of dopamine in the RCABG patients. CK-MB release was significantly (p less than 0.05) greater in RCABG patients. Serious postoperative complications (CK-MB greater than or equal to 15 IU/L, low cardiac output, and death) were significantly (p = 0.02) greater in the RCABG group. It is concluded that RCABG patients represent a greater risk of complications and that new strategies for improving myocardial protection need to be developed to reduce the risk.

Topics: Adult; Aged; Anesthesia, Endotracheal; Cardiac Output, Low; Cardiovascular Agents; Coronary Artery Bypass; Dopamine; Humans; Hypotension; Middle Aged; Nitroglycerin; Nitroprusside; Postoperative Period; Reoperation; Retrospective Studies; Risk

Toxicity from cardiac drugs is a particular management challenge since the manifestations of an acute overdose and the initial indications for the drug are often similar. Plasma drug levels are essential but must be interpreted in light of the clinical picture. Hypotension, due to either vasodilatation or decreased myocardial contractility, and arrhythmias are the principal cardiac manifestations, but noncardiac effects are sometimes more troublesome. An antiarrhythmic agent of the same class should not be used in treating an arrhythmia resulting from an overdose.

Topics: Arrhythmias, Cardiac; Bretylium Compounds; Cardiovascular Agents; Cardiovascular Diseases; Digoxin; Disopyramide; Humans; Hypotension; Lidocaine; Liver; Phenytoin; Procainamide; Propranolol; Quinidine; Vasodilator Agents

Topics: Animals; Cardiovascular Agents; Cats; Gallamine Triethiodide; Hypotension; Muscle Relaxants, Central

Topics: Cardiovascular Agents; Dihydroergotoxine; Ergot Alkaloids; Hypotension; Hypotension, Orthostatic

Topics: Antihypertensive Agents; Cardiovascular Agents; Humans; Hypotension; Muscle Relaxants, Central; Reserpine; Theophylline

Topics: Antihypertensive Agents; Cardiovascular Agents; Humans; Hypotension; Muscle Relaxants, Central; Sympatholytics

Topics: Cardiovascular Agents; Ergot Alkaloids; Hypertension; Hypotension

Topics: Anesthesia; Anesthesiology; Body Temperature; Cardiovascular Agents; Hibernation; Hypotension; Muscle Relaxants, Central

Topics: Blood Circulation; Cardiovascular Agents; Hexamethonium; Hypotension; Muscle Relaxants, Central

Topics: Blood Circulation; Cardiovascular Agents; Hypertension; Hypotension; Muscle Relaxants, Central; Sympatholytics; Veratrum Alkaloids

Topics: Bis-Trimethylammonium Compounds; Cardiovascular Agents; Hemostasis; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central

Topics: Cardiovascular Agents; Hexamethonium; Hypotension; Muscle Relaxants, Central

Topics: Blood Vessels; Cardiovascular Agents; Hemodynamics; Humans; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central

Topics: Bis-Trimethylammonium Compounds; Cardiovascular Agents; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central; Thorax

Topics: Blood Pressure; Cardiovascular Agents; Hexamethonium; Hypertension; Hypotension; Muscle Relaxants, Central; Salts

Topics: Cardiovascular Agents; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central

Topics: Cardiovascular Agents; Hexamethonium; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central; Procainamide; Procaine

Topics: Cardiovascular Agents; Hypotension; Hypotension, Controlled; Leg; Muscle Relaxants, Central; Neurosurgery; Neurosurgical Procedures; Suction

Topics: Cardiovascular Agents; Hexamethonium; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central; Neurosurgery; Neurosurgical Procedures; Procainamide; Procaine

Topics: Cardiovascular Agents; Hypotension; Intubation; Muscle Relaxants, Central; Stupor

Topics: Cardiovascular Agents; Heart; Hypotension; Muscle Relaxants, Central; Parasympatholytics

Topics: Cardiovascular Agents; Dihydroergotoxine; Ergot Alkaloids; Hypotension; Oxytocics

Topics: Cardiovascular Agents; Hexamethonium; Hydralazine; Hypertension; Hypotension; Muscle Relaxants, Central; Phenoxybenzamine; Salts; Sympatholytics; Tetraethylammonium

Topics: Autonomic Agents; Cardiovascular Agents; Hexamethonium; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central

Topics: Cardiovascular Agents; Hexamethonium; Humans; Hypotension; Muscle Relaxants, Central

Topics: Anesthetics; Cardiovascular Agents; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central

Topics: Blood Loss, Surgical; Cardiovascular Agents; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central

Topics: Cardiovascular Agents; Cortisone; Hexamethonium; Hypotension; Muscle Relaxants, Central

Topics: Cardiovascular Agents; Cortisone; Hexamethonium; Hypotension; Muscle Relaxants, Central; Rheumatic Diseases

Topics: Barbiturates; Cardiovascular Agents; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central

Topics: Cardiovascular Agents; Ergot Alkaloids; Ergotamine; Hypotension; Isoproterenol; Norepinephrine; Oxytocics; Research

Topics: Body Fluids; Cardiovascular Agents; Electrolytes; Hexamethonium; Hypotension; Muscle Relaxants, Central; Water

Topics: Cardiovascular Agents; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central

Topics: Blood Pressure; Blood Pressure Determination; Cardiovascular Agents; Ergot Alkaloids; Ergotamine; Humans; Hypotension; Isoproterenol; Sympatholytics

Topics: Cardiovascular Agents; Hexamethonium; Hypotension; Muscle Relaxants, Central; Neurosurgery; Neurosurgical Procedures

Topics: Cardiovascular Agents; Hemorrhage; Hypotension; Hypotension, Controlled; Muscle Relaxants, Central

Topics: Bis-Trimethylammonium Compounds; Cardiovascular Agents; Hypotension; Muscle Relaxants, Central

Topics: Blood Vessels; Cardiovascular Agents; Humans; Hypotension; Muscle Relaxants, Central; Vasoplegia

Topics: Blood Pressure; Cardiovascular Agents; Humans; Hypertension; Hypotension; Injections; Muscle Relaxants, Central; Syringes

Topics: Cardiovascular Agents; Ergot Alkaloids; Humans; Hypotension; Injections, Intravenous; Oxytocics