A Successful Resuscitation of a Young Patient with Persistent Life Threatening Ventricular Fibrillation during a Minor Surgical Procedure.

Aims: A discussion about the treatment options for cardiac arrest due to cocaine toxicity. Presentation of Case: This is a case report of a young man who underwent general anesthesia for a urologic procedure. He suffered a ventricular fibrillation arrest and required over an hour of Advanced Cardiac Life Support (ACLS). Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPS) techniques were utilized. Within one hour from the initiation of the dysrhythmia he received femoral vessel cannulation in preparation for extracorporeal membrane oxygenation (ECMO). The hypothermia protocol was instituted early for brain protection. The patient completely recovered with no neurological or cardiovascular sequelae from this life threatening cardiac arrest. Upon further investigation, it was discovered that cocaine was consumed one day prior to surgery. Discussion: The use of cocaine is associated with multiple cardiovascular complications including ventricular fibrillation which was the probable etiology of this patient’s dysrhythmia. Recent studies elicited that there are underlying anatomic substrate alterations and changes in the molecular structure when cocaine is used. Cocaine stabilizes membranes in the nervous and myocardial tissue by antagonizing sodium and potassium channels. Multiple interventions were utilized which resulted in a successful resuscitation. Conclusion: The implementation of ACLS, ECMO, hypothermic brain protection and team training all aided in the complete neurologic recovery in this patient.

Infarto agudo al miocardio en pacientes menores de 40 años: características clínicas, angiográficas y alternativas terapéuticas / Acute myocardial infarction in patients under 40 years of age: clinical and angiographic characteristics: therapeutic options

Objetivos: Analizar comparativamente las características clínicas y angiográficas, y el tratamiento utilizado, en pacientes jóvenes cursando un infarto agudo del miocardio (IAM) con supradesnivel del segmento ST (SDST). Métodos: Análisis retrospectivo de los pacientes que se presentaron con un IAM con SDST y fueron sometidos a angiografía coronaria durante el período entre enero de 2009 y diciembre de 2011. Se identificó a los pacientes menores de 40 años y se registraron sus características clínicas y angiográficas, las terapias utilizadas y sus resultados a mediano plazo. Estos datos fueron comparados con los pacientes de 40 o más años atendidos durante el mismo período. Resultados: De 613 IAM con SDST, 40 (6,5 por ciento) casos correspondieron a menores de 40 años (edad promedio 36,6 años). De éstos, 7 (17,5 por ciento) fueron mujeres, 32 (80 por ciento) fumadores y 17 (42,5 por ciento) referían uso de cocaína. La mayoría presentó alta carga trombótica (TIMI Thrombus Grade 4/5 en 87,5 por ciento), pero con enfermedad de baja severidad anatómica (Syntax Score promedio 13,1 (DE 5,8)). Treinta (75 por ciento) pacientes recibieron an-gioplastía con stent y 21 (52,5por ciento) aspiración de trombos. El seguimiento tardío reveló 5 (12,5 por ciento) eventos mayores. Comparado con los pacientes mayores de 40 años, la mortalidad al año fue marcadamente inferior: 2,5 por ciento versus 12 por ciento, p<0,01. Conclusiones: En menores de 40 años con IAM con SDST, el tabaquismo, uso de cocaína, fueron los principales factores asociados. Aunque la enfermedad coronaria anatómica no fue severa, hubo una gran carga trombótica en la mayoría de los pacientes. Esto se asoció a escasos eventos cardiovasculares y una mortalidad menor a la de los pacientes mayores.

Aim: To analyze clinical and angiographic characteristics and the treatment provided to young patients admitted with an ST-elevation myocardial infarction (STEMI). Methods: Retrospective analysis of patients with STEMI who were invasively studied from January 2009 through December 2011. Clinical and angiogra-phic data, as well as phone follow-ups and mortality registries were reviewed for each patient younger than 40 years old. These results were compared with those from STEMI patients who had 40 or more years of age during the same time period. Results: From 613 STEMI patients, 40 (6.5 percent) had less than 40 years (average age 36.6 years). Among these, 7 (17.5 percent) were females, 32 (80 percent) were active smokers and 17 (42.5 percent) recognized cocaine abuse. Whereas most patients presented with high thrombus content (TIMI Thrombus Grade 4/5 in 87.5 percent), the burden of atherosclerotic coronary disease was markedly low (average Syntax Score 13.1 (SD 5.8)). Coronary stents were used in 30 (75 percent) patients and thrombus aspiration in 21 (52.5 per cent). Late follow-up showed 5 (12.5 percent) major cardiovascular events. In comparison with older patients, 1-year mortality was significantly lower for young patients: 2.5 percent versus 12 per cent, p<0.01. Conclusions: Younger patients with STEMI frequently smoke and use cocaine. Although the burden of coronary disease was low, most patients had a high thrombus content. Cardiovascular events and mortality were lower compared to older patients.

Daño endotelial y activación del sistema hemostático asociado al uso crónico de cocaína: estudios ex vivo e in vitro / Endothelial damage and activation of the haemostatic system associated to chronic use of cocaine: an ex vivo and in vitro study

Antecedentes: Usuarios crónicos de cocaína tienen riesgo aumentado de presentar infarto de miocardio, angina,muerte súbita y accidentes cerebrovasculares. Aunque la patogenia del daño vascular es mayormente desconocida, se ha encontrado arterioesclerosis prematura y formación de trombos intravasculares. Objetivo: Demostrar evidencia de daño endotelial y activación del sistema hemostático en usuarios crónicos de cocaína. Métodos: Un grupo de 23 pacientes con criterios de dependencia a cocaína DSM-IV; 19 hombres (edad promedio 32 a), con exposición a la droga dentro de 72 h del estudio. Disfunción endotelial se evaluó por enumeración de las células endoteliales circulantes (CEC) y nivel de sICAM . Para activación del sistema hemostático se incluyó: complejos trombina-antitrombina (TAT) y generación de trombina; NAP-2 y RANTES para activación plaquetaria. In vitro, CE en cultivo (HUVEC), se expusieron a plasma de consumidores o controles. Se midió factor von Willebrand (FVW) en el medio y expresión de FvW y factor tisular (FT) sobre las CE. Adhesión plaquetaria estática se evaluó por microscopía. Resultados: En usuarios de cocaína, con respecto a controles, las CEC estaban significativamente elevadas...

Background: chronic cocaine users have an increased risk of developing myocardial infarction, angina, suddendeath and stroke. Although the pathogenesis of this effect is not completely known, premature atheromatosis and intravascular thrombosis appear to be involved.Aim: to provide evidence for the presence of endothelial damage and activation of the haemostatic system in chronic cocaine users. Methods: 23 subjects (19males, overall mean age 32) with DSM-IV criteria for cocaine dependency and exposure to the drug within 72 hours were studied. Endothelial dysfunction was determined by circulating endothelial cell counts (CEC) and sICAM levels. Thrombin-antithrombin complexes (TAT) and thrombin generation were used to characterize haemostatic status. In vitro, platelet activation was studied by NAP-2 and RANTES. EC in culture (HUVEC) were exposed to plasma from cocaine users and controls. Von Willebrand factor was measured in the culture media as well as its expression along with that of tissue factor in EC. Platelet adhesion was evaluated by microscopy. Results: Compared to controls, EC were significantly increased in cocaine users...