Buccal caffeine strips for reversal of adverse symptoms of vasodilator stress.

BACKGROUND: Due to recurrent shortages of aminophylline, intravenous caffeine has emerged as a commonly used, safe and reliable method to treat adverse effects of vasodilator stress agents. We sought to evaluate the safety and effectiveness of buccal caffeine strips which are rapidly absorbed, inexpensive, readily available, and simplify caffeine administration. METHODS: Consecutive patients undergoing regadenoson stress SPECT MPI were assessed for the occurrence of symptoms during testing over an 11-week period at a single metropolitan hospital. Adverse symptoms, including their severity and duration, were recorded at the time of testing. Patient satisfaction was rated on a scale of 1 to 5 (5 being the most satisfied). Patients received reversal with caffeine if symptoms were felt to be significant enough by the patient and physician performing the test. The treatment received alternated week to week between IV caffeine (60 mg) or 100 mg buccal caffeine strips. Caffeine was given at least 3 minutes after tracer injection. A rescue dose of IV caffeine was offered 10 minutes later if indicated. RESULTS: Of the 122 patients enrolled in the study, 70 (57%) were included during buccal caffeine weeks and 52 (43%) during IV caffeine weeks, and only 28 (24%) received reversal with a caffeine agent. Seven (6%) received IV caffeine and 21 (17%) received buccal caffeine. There was no significant difference in symptom duration between IV and buccal caffeine after treatment (152.8 vs 163.4 seconds, P = 0.87). There was no significant difference in initial and final symptom severity between groups. Only 2 patients in the buccal group required rescue IV caffeine for ongoing symptoms and emesis. None of the IV group required a rescue dose. There was no significant difference in patient satisfaction between the groups (2.8 vs 3.2, P = 0.38). CONCLUSION: Buccal caffeine strips are a safe, well tolerated, and effective initial strategy to reverse adverse effects of vasodilator stress in the minority of patients who request it. Buccal caffeine alone or with IV rescue caffeine was highly effective in reversing adverse effects and was free of major adverse clinical events.

A Case Report: Point-of-care Ultrasound in the Diagnosis of Post-Myocardial Infarction Ventricular Septal Rupture.

INTRODUCTION: Ventricular septal rupture (VSR) is a rare complication of ST-elevation myocardial infarction (STEMI), typically discovered post-revascularization. CASE REPORT: We present the first case of VSR detected on point-of-care ultrasound (POCUS) in the emergency department immediately prior to emergent angiography, with management positively affected by this discovery. The VSR was quickly confirmed via right heart catheterization. Subsequently, hemodynamic stability was achieved using an intra-aortic balloon pump. A delayed surgical VSR repair, with concomitant coronary artery bypass grafting, was implemented for definitive management. CONCLUSION: This case highlights the utility of POCUS in a STEMI patient with a suspected mechanical complication.

Prognostic Usefulness of Systolic Blood Pressure One-Year Following Cardiac Resynchronization Therapy (from MADIT-CRT).

Low systolic blood pressure (SBP) is associated with increased mortality and heart failure in patients with left ventricular dysfunction. Data on the relation between SBP measured following cardiac resynchronization therapy implantation and subsequent clinical events are limited. We hypothesized that assessment of systolic blood pressure at 12 months after cardiac resynchronization therapy can be used to identify patients with increased risk for adverse cardiovascular outcomes. The study population comprised 1000 patients who underwent cardiac resynchronization therapy implantation in MADIT-CRT. Outcomes were compared between patients with low (<110 mm Hg) and preserved SBP (≥110 mm Hg) at 1 year. At 1 year following cardiac resynchronization therapy, 800 patients (80%) had preserved systolic blood pressure. Kaplan-Meier survival analysis showed that the rate of heart failure or death during subsequent follow-up was significantly higher among patients with low SBP as compared with a preserved SBP at 12 months (2-year rates: 20% vs 12%, respectively; log-rank p value = 0.009 for the overall difference during follow-up). Consistently, multivariate analysis showed that patients with preserved SBP at 1 year had a 29% lower risk of HF or death when compared with the low SBP group (p = 0.024). The association between SBP measured following cardiac resynchronization therapy implantation and subsequent clinical events was more pronounced among patients with nonischemic cardiomyopathy (p value for SBP-by-HF etiology interaction = 0.034). In conclusion, assessment of SBP following cardiac resynchronization therapy can be used for improved long-term risk stratification in this population.