State-of-the-art paper: Therapeutic hypothermia in out of hospital cardiac arrest survivors.

Out of hospital cardiac arrest (OHCA) is associated with an extremely poor survival rate, with mortality in most cases being related to neurological injury. Among patients who experience return of spontaneous circulation (ROSC), therapeutic hypothermia (TH) is the only proven intervention shown to reduce mortality and improve neurological outcome. First described in 1958, the field of TH has rapidly evolved in recent years. While recent technological advances in TH will likely improve outcomes in OHCA survivors, several fundamental questions remain to be answered including the optimal speed of cooling, which patients benefit from an early invasive strategy, and whether technological advances will facilitate application of TH in the field. An increased awareness and understanding of TH strategies, devices, monitoring, techniques, and complications will allow for a more widespread adoption of this important treatment modality.

Effect of Hurricane Katrina on chronobiology at onset of acute myocardial infarction during the subsequent three years.

The onset of acute myocardial infarction (AMI) has been shown to occur in a nonrandom pattern, with peaks in midmorning and on weekdays (especially Monday). The incidence of AMI has been shown to increase locally after natural disasters, but the effect of catastrophic events on AMI biorhythms is largely unknown. To assess the differences in the chronobiology of AMI in residents of New Orleans before and after Hurricane Katrina, the onset of AMI in patients at Tulane University Health Sciences Center in the 6 years before and the 3 years after Hurricane Katrina was retrospectively examined. Compared to the pre-Katrina group, the post-Katrina cohort demonstrated significant decreases in the onset of AMI during mornings (p = 0.002), Mondays (p <0.0001), and weekdays (p <0.0001) and significant increases in onset during weekends (p <0.0001) and nights (p <0.0001). These changes persisted during all 3 years after the storm. In conclusion, the normal pattern of AMI onset was altered after Hurricane Katrina, and expected morning, weekday, and Monday peaks were eliminated.

Diagnosis of arrhythmogenic right ventricular cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an infrequently diagnosed condition with a high incidence of sudden cardiac death. While the only option for cure is orthotopic cardiac transplantation, the use of an implantable cardiac defibrillator can be life saving. Accordingly, the prompt recognition of ARVC is crucial. Fortunately, a definitive diagnosis of ARVC can often be made by a combination of the clinical history and electrocardiogram alone, as illustrated by the present case. In our patient, who presented with multiple syncopal episodes and in whom ventricular tachycardia was observed shortly after her admission to the emergency department, a lengthy and expensive workup was initiated, which ultimately may have delayed implantation of an implantable cardiac defibrillator. Clinicians should be made aware of the clinical guidelines for dealing with this potentially dangerous condition so that appropriate therapy can be promptly initiated.

Epidural Anesthesia for Cesarean Delivery in a Patient With Severe Pulmonary Artery Hypertension and a Right-to-Left Shunt.

A 38-year-old woman with severe pulmonary artery hypertension and a right-to-left shunt of unknown etiology presented at 32 weeks' gestational age. Determination of the cause of her pulmonary hypertension by transesophageal echocardiography was delayed until after delivery secondary to anesthetic risk. She was successfully anesthetized for cesarean delivery using epidural anesthesia. Systemic vascular resistance was maintained using phenylephrine hydrochloride before delivery and vasopressin after delivery. Transesophageal echocardiography after delivery revealed a patent foramen ovale, indicating a diagnosis of idiopathic pulmonary artery hypertension and a very poor prognosis. Differentiating between Eisenmenger syndrome and idiopathic pulmonary artery hypertension may not be important for determining the optimal anesthetic management of patients with pulmonary hypertension but is important in assessing long-term prognosis.

Induced hypothermia prior to left ventricular assist device.

Induced hypothermia, a therapy that recently gained the attention of a broad spectrum of US and international medical authorities for its neuroprotective benefits in post-cardiac arrest patients, may represent an underexplored therapeutic option in patients with severe cardiac failure by optimizing hemodynamics and augmenting cardiac contractility. The authors present the first case report, to their knowledge, of a patient with severe congestive heart failure who underwent cooling prior to successful left ventricular assist device implantation.

Induced hypothermia as a neuroprotectant in post-cardiac arrest.

Survivors of out-of-hospital cardiac arrest frequently suffer devastating effects from anoxic brain injury. Therapeutic hypothermia is the first therapy to show benefit in improving survival as well as limiting neurologic injury. We review the data supporting the use of therapeutic hypothermia in this patient population, the pathophysiologic basis of its neuroprotectant effects, the methods of hypothermic induction, and the clinical application.

The role of fish oil in arrhythmia prevention.

Numerous epidemiological studies, case-control series, and randomized trials have demonstrated the ability of fish oil to reduce major cardiovascular events, particularly sudden cardiac death and all-cause mortality. We discuss the potential benefits of fish oil therapy to improve overall autonomic tone and potentially reduce the risk of major ventricular and atrial arrhythmias. Specifically, this review focuses on how fish oil therapy has performed in 3 primary prevention trials in patients with implantable cardioverter defibrillators, reviews the effects that fish oil has on the autonomic nervous system, focuses on the use of fish oil as a novel therapy for atrial fibrillation, and revisits other beneficial properties of fish oil (ie, ability to lower serum triglycerides, anti-inflammatory effects, and possible improvements in arterial pressure/diastolic function). We also discuss the safety profile of fish oil, including effects on bleeding time and bleeding complications as well as provide commentary regarding fish oil supplementation in light of increasing contaminants contained in fish. In summary, any patient with documented coronary heart disease and those with risk factors for sudden cardiac death, such as left ventricular dysfunction, left ventricular hypertrophy, prior myocardial infarction, or high-grade ventricular dysrhythmias, should consider fish oil supplementation. The American Heart Association recommends four 3-ounce servings of oily fish weekly. For those who cannot eat fish or do not have access to fish, as well as those who would prefer not to eat fish regularly, capsules of fish oil are readily available in various concentrations. At the present time, we recommend doses of eicosapentanoic acid and docosahexanoic acid in the combined range of 800 to 1000 mg/day for primary and secondary prevention of cardiovascular disease.