Síndrome de respuesta inflamatoria sistémica por ticagrelor / Systemic inflammatory response syndrome associated with use of ticagrelor

Resumen El ticagrelor es un antiagregante plaquetario que actúa a través de la unión reversible a los receptores P2Y12 de la adenosina-difosfato. En el síndrome coronario agudo, ha demostrado reducir el riesgo de eventos cardiovasculares mayores como infarto de miocardio, accidente cerebrovascular y muerte. Si bien se han descripto en detalle ciertas complicaciones hemorrágicas, renales, hepáticas y respiratorias por el uso del ticagrelor, otros efectos adversos menos frecuentes de la droga no han sido adecuadamente escla recidos. Presentamos el caso de un paciente con un síndrome de respuesta inflamatoria sistémica secundario al uso de ticagrelor.

Abstract Ticagrelor is anantiplatelet agent which acts through reversible binding to the P2Y12 adenosine-diphosphate recep tors. In acute coronary syndromes it has been shown to reduce the risk of major cardiovascular events such as myocardial infarction, stroke and death. Although some hemorrhagic, kidney, liver and respiratory complications have been described in detail with the use of ticagrelor, other less frequent adverse effects are not so well clari fied. We report the case of a patient with a systemic inflammatory response syndrome secondary to the use of ticagrelor.

Arritmias na sala de emergência e UTI. Taquicardias de QRS estreito: fundamentos para a abordagem / Arrythmias in the emergency room and ICU Narrow QRS rachycardias: bases for clinical approach

As taquicardias de QRS estreito apresentam origem supraventricular. O histórico clínico, exame físico e eletrocardiograma na sala de emergência constituem-se nas principais ferramentas para o tratamento do quadro. As taquicardias que apresentam instabilidade hemodinâmica devem ser, imediatamente, revertidas através de cardioversão elétrica sincronizada. Aquelas que se apresentam como estáveis hemodinamicamente podem, se regulares, ser tratadas através de manobras vagais ou através do uso de fármacos endovenosos. Se irregulares, podem caracterizar fibrilação e flutter atrial, sendo, então, avaliados a duração do episódio e o risco de tromboembolismo para determinar não apenas a necessidade de anticoagulação, mas também a estratégia para tratamento do quadro, seja através do controle da frequência cardíaca ou do controle do ritmo, este último podendo ser alcançado através do uso de fármacos (propafenona oral ou amiodarona endovenosa) ou da cardioversão elétrica sincronizada. Dessa forma, o papel do clínico na sala de emergência é fundamental para garantir a condução adequada dos episódios de taquicardia supraventricular, especialmente, na prevenção ou pronta intervenção em caso de deterioração hemodinâmica relacionada ao quadro

Narrow QRS tachycardias are supraventricular in origin. The clinical history, physical exam, and electrocardiogram in the emergency room are the main tools used to manage this condition. Tachycardias that present haemodynamic instability must be promptly reverted through synchronized electrical cardioversion. Those that present haemodynamic stability may be treated with vagal maneuvers or intravenous drugs. If irregular, they may take the form of atrial fibrillation or atrial flutter, and in this case, the duration of the episode and the thromboembolic risk are evaluated to determine not only the need for anticoagulation, but also the treatment strategy, whether through heart rate or rhythm control. The latter may be achieved through the use of drugs (oral propafenone or intravenous amiodarone) or synchronized electrical cardioversion. The role of the clinician in the emergency room is therefore fundamental in ensuring adequate conduct of episodes of supraventricular tachycardia, especially in prevention or prompt intervention in case of haemodynamic deterioration related to the condition

Development of Coronary Vasospasm during Adenosine-Stress Myocardial Perfusion CT Imaging

Adenosine is a short-acting coronary vasodilator, and it is widely used during pharmacological stress myocardial perfusion imaging. It has a well-established safety profile, and most of its side effects are known to be mild and transient. Until now, coronary vasospasm has been rarely reported as a side effect of adenosine during or after adenosine stress test. This study reports a case of coronary vasospasm which was documented on stress myocardial perfusion CT imaging during adenosine stress test.

Efficacy of adenosine for acute treatment of supraventricular tachycardia in infants and children

This study was done to assess the efficacy and adverse effects of the different doses of adenosine in the pediatric age group with respect to multiple patient variables. Over a period of 1 year, 86 occasions of supraventricular tachycardia [SVT] were treated with adenosine in 81 infants and children aged between 18 days and 12 years [median of 1.3 years, SD=3]. Adenosine efficacy was evaluated in terms of the patients' demographics, SVT rate, electrocardiogram characteristics, and route of drug administration. The dose of 50microg/kg was effective only in 24% of the SVT cases, and the additional doses of 100microg/kg, 150microg/kg, and 200microg/kg were effective in another 29% of the cases. The drug efficacy was higher in the infants than that in the older children. There were no predictors other than age for the estimation of the efficacy of the drug. Our findings showed that the current recommended doses of adenosine are ineffective in the vast majority of children and infants with SVT. No patient-related factor other than age seems to affect the efficacy of the drug

Perfusão miocárdica por ecocardiografia de contraste com microbolhas: valor prognóstico de médio a longo prazo em pacientes com suspeita (baixa, média ou alta probabilidade)ou com doença arterial coronariana confirmada / Myocardial perfusion by microbubbles contrast echocardiography: long-term prognostic value in patients with known or suspected (at low-intermediate, or high-risk) coronary artery disease

Acompanhamos para eventos cardíacos tardios (EC) 487 pts submetidos à ecocardiografia de contraste miocárdico ECM por 36+17 meses. Defeito reversível de perfusão foi positivo (POS) e normal ou defeito fixo isolado foi negativo (NEG). Os pts foram considerados de baixo(87), intermediário(94) e alto risco(141), ou com doença arterial coronária (DAC) confirmada(165). Foram documentados 85 EC: morte cardíaca (15), infarto do miocárdio (7) e revascularização miocárdica (63). POS foi preditor independente para EC. A sobrevida acumulada livre de eventos foi 96 por cento e 77 por cento para pts com ECM NEG e POS respectivamente (p<0,001). ECM é útil preditor para EC em pts com suspeita ou DAC confirmada / Long-term predictive value for late cardiac events (CE) was determined in 487 patients who underwent myocardial contrast echocardiography (MCE) and were followed up for 36+17 months. Reversible perfusion defects were positive (POS) and normal or isolated fixed defects were negative (NEG). Patients were at low (87), intermediate (94), high-risk (141), or with confirmed coronary disease (165). CE were: cardiac death (15), non-fatal myocardial infarction (7), and revascularization (63) patients. POS test was an independent predictor of CE. The cumulative event free survival was 96 per cent (NEG-MCE) and 77 per cent (POS-MCE), p<0.001. MCE was a useful predictor of CE...

Adenosine-induced ventricular fibrillation.

The use of adenosine has been suggested as a diagnostic tool in the evaluation of wide ORS complex tachycardia. However, adenosine shortens the antegrade refractoriness of accessory atrioventricular connections and may cause acceleration of the ventricular rate during atrial fibrillation. We observed ventricular fibrillation in 2 patients who presented to the emergency department with pre-excited atrial fibrillation and were given 12 mg of adenosine.

How safe is adenosine when used as a pharmacologic stressing agent in myocardial perfusion scintigraphy?

Myocardial perfusion imaging is used in the assessment of coronary artery disease by stressing patients either physically or pharmacologically. Adenosine was used as a pharmacologic stressor when administered at a dose of 0.14 mg/kg/min for 6 min to determine its safety at this dose level. Twenty patients referred for myocardial perfusion imaging were stressed with adenosine. The protocol was completed in 18 patients; 1 patient needed early termination of the infusion while another patient needed dose reduction. There patients did not experience any side effects and 17 patients experienced side effects that were short-lived. All the patients showed good tolerance to the test. Hence adenosine is a safe pharmacologic stressor at this dose level for myocardial perfusion imaging