Cardiac

Post-Operative Atrial Fibrillation

Post-operative atrial fibrillation has been viewed as a transient or more benign phenomenon than non-valvular atrial fibrillation in chronic settings. This registry study showed that it occurred in 0.4% after non-cardiac surgery, more common after thoracic, vascular and abdominal surgery, and more likely in older patients with co-morbidities. After follow-up for some 3 years, the rate of thromboembolism was similar to those with non-valvular atrial fibrillation.

The authors recommend reconsideration of guidelines for anticoagulation in these patients at risk of thromboembolism and stroke.

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Post-Resuscitation Elevated Blood Pressure and Outcome

In a preplanned analysis of a prospective cohort study, elevated blood pressure during the initial 6 hours after resuscitation from cardiac arrest was independently associated with good neurologic function at hospital discharge. Outcome was better with mean arterial pressure above 90mm Hg, with the strongest association above 110mm Hg. Further study is needed to determine causation as opposed to correlation and whether targeted intervention can improve outcome.

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Resuming Beta Blockers Post-op

For those taking chronic beta-blockers in non-cardiothoracic, non-vascular surgery, resumption on post op day 1 reduces the risk of Atrial Fibrillation (although no evidence supported resuming earlier, on surgery day).

Chronic medications frequently fall through the cracks in the peri-operative setting and efforts to resume these agents in the absence of contraindications should be encouraged. Thromboembolic events could occur even in the brief peri-operative setting.

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Antiplatelet Duration for Stent after MI

Current recommendations specify 6 months dual antiplatelet therapy (DAPT) after PCI in stable ischemic heart disease and 12 months after acute coronary syndromes. This new study looked at DAPT after STEMI and found: “Limiting DAPT duration to six months in patients with STEMI that are event-free results in a non-inferior clinical outcome, as assessed by a patient-oriented composite clinical endpoint versus 12 months of DAPT”. Aspirin was continued after this 6 month period.

While the guidelines remain, these findings are reassuring in that a shorter duration of DAPT may be reasonable especially insofar as surgical procedures are impacted often by delaying for 12 months.

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Systemic Inflammation and myocardial injury

Inflammation is thought to be central in the pathogenesis of cardiovascular disease and this study found that one indicator, the Neutrophil-Lymphocyte Ratio > 4 is associated with perioperative myocardial injury, independent of conventional risk factors. The role of inflammation and its possible modification to reduce myocardial injury is an interesting area for future study.

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Targeted Temperature in ICU

A French expert consensus on targeted temperature management summarizes the evidence. They recommend 32-36° after out of hospital cardiac arrest with shockable rhythm who remain comatose, and also to consider in the in-hospital scenario. Normothermia is recommended in pediatrics.

35-37° is their target for severe traumatic brain injury, which may also control intracranial pressure; again, normothermia is the pediatric goal.

Normothermia is the goal for ischemic stroke, and 35-37° for comatose intracranial hemorrhage.

32-35° is recommended for refractory status epilepticus (but normothermia in pediatrics). Normothermia for meningitis, or 34-36° with intracranial hypertension.

Implementation, monitoring, rewarming and other evidence is discussed in the link:

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Sedation and Neuromuscular Blockade after Cardiac Arrest

Different combinations of sedation and neuromuscular blocking agents were used post cardiac arrest with targeted temperature management: no blockade, scheduled, or as needed. It was found that cardiac arrest patients treated at centers using as-needed neuromuscular blockade had increased odds of good outcomes compared with centers using escalating sedation doses and avoidance of neuromuscular blockade, after adjusting for potential confounders.

Shivering prevention, reduced oxygen consumption, harmful effects of sedation or other confounders are all postulated effects that will require further elucidation but there is a recent return to the use of judicious neuromuscular blocking agents in critical care.

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Troponin Elevation in Critical Care

Troponin elevations are associated with increased mortality and adverse cardiovascular outcomes in critical illness, but not necessarily implying myocardial infarction, often better termed injury.  Such a diagnosis needs integration of clinical history, EKG, Echocardiogram etc. How this affects diagnosis and management of patients with elevated Troponin is discussed in the link below:

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Nicotine Replacement in Hospitalized Coronary Patients

Some concern exists as to the cardiac safety of using nicotine replacement patches in cardiac disease. The majority of studies indicate it safe to use in stable disease but this observational study is reassuring in finding: “Among smokers hospitalized for treatment of coronary heart disease, use of nicotine replacement therapy was not associated with any differences in short‐term outcomes”.

Outcomes included inpatient mortality, hospital length of stay, and one-month readmission.

These patients had a high degree of cardiac acuity but the authors caution that, due to the known cardiovascular effects of nicotine, randomized along with longer term studies are needed to confirm these reassuring findings in tackling smoking cessation at an early stage of hospitalization.

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