Bicuspid Aortic Valve and Mitral Valve Prolapse

In recent years the guidelines for bacterial endocarditis antibiotic prophylaxis have been drastically curtailed. This Spanish study calls for reconsideration, in that patients with bicuspid aortic valves and mitral valve prolapse had viridans endocarditis with a similar profile to other high risk endocarditis cases.



Hypertension and Intra-operative Hemodynamics

An observational study fails to link pre-op hypertension to adverse intra-op hemodynamics like hypotension and tachycardia, factors known to increase major adverse cardiovascular morbidity and mortality. It supports AAGBI guidelines and others to continue with elective surgery in patients with blood pressure less than 180/110



Dabigatran for Myocardial Injury in Non-Cardiac Surgery

In the MANAGE trial, the use of 110mg bid Dabigatran reduced the incidence of major vascular complications (without an increase in bleeding) after myocardial injury within 35 days of non-cardiac surgery. The difference wasn’t huge and the trial stopped early, and discontinuance rates of Dabigatran were high. The myocardial injury consisted of isolated Troponin elevations in 80% of cases. Low enrolment and change of primary endpoint were further limitations. So the question of monitoring Troponin levels continues as interventions are needed and this study is not overwhelmingly convincing in lowering death from MI, Stroke and other vascular complications.



Blood Pressure, Heart Rate and Myocardial Injury

Myocardial Injury after non-cardiac surgery (MINS) was studied and a clear and unsurprising correlation was seen with intra-operative hypotension and tachycardia. Previous studies have demonstrated this as well as the duration of hypotension, and mean arterial pressures less than 65 mm Hg should not be tolerated for more than 5 minutes, especially urgent in older patients and/or cardiovascular disease co-occurrence.  The interval between induction and surgery commencement is particularly noted for such hypotension.


Mechanical CPR Devices

To lessen the burden of CPR, mechanical devices have been developed to lessen the load on caregivers. They include load distributing (Autopulse) and piston devices (LUCAS). Theoretical advantages are better and more consistent chest compressions.

Numerous studies reviewed here have  however not shown an improvement in the outcome. The best recommendation pending further studies seems to be to consider in special difficult circumstances like in imaging or PCI areas or in air transport. Deployment time needs to be minimized if used, so as not to interrupt manual CPR.



Extracorporeal Pediatric CPR

A small retrospective study of 56 Pediatric cardiac arrests (80% related to primary cardiac conditions), mean age 3.5 months (1-53).

Survival to hospital discharge was a very good c. 65%, best in younger age (3.5 months) and those with decreased extracorporeal CPR tones and those exposed to therapeutic hypothermia. Follow up showed a good quality of life and family functioning. Further studies are needed to establish whether the technique should be more widely available in Pediatric critical care.



Clinic vs Ambulatory Blood Pressure

An important study from general medicine that impacts us in our pre-admission service. Always seeing patients who say their hypertension is only when they come to hospital – white coat hypertension. This, and it’s opposite – masked hypertension (even more) is shown to be associated with mortality and cardiovascular assessment and advice should be so tailored.

“Ambulatory blood-pressure measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic blood-pressure measurements. White-coat hypertension was not benign, and masked hypertension was associated with a greater risk of death than sustained hypertension“.

nejm link