Inotropes Are Not Linked to Increased Mortality in Heart Failure

How to use inotropes is one of the most controversial topics in the management of heart failure. While most clinicians use these drugs, and recognize the state of inotrope dependency, current guidelines recommend them onlu as a bridge or palliation. Thus, inotropes are considered either neutral or detrimental in terms of outcomes. Meanwhile, properly designed randomized clinical trials testing the outcomes on inotropes, have never been performed and it is unlikely that they will ever be attempted. These trials would require randomizing patients with advanced heart failure, low output syndrome, and impaired end-organ perfusion into groups that received or not received inotropes, or received inotropes or placebo. Many physicians would consider this design unethical so the trials would be challenging to implement. But if it is unethical to deny inotropes to this subset of patients, we have to admit that inotropes do not only improve quality of life, but prolong it, or decrease mortality. Otherwise, we consider it unethical to deny the medication which increases mortality. In this review, we analyze the current evidence relating to inotropes and outcomes. We demonstrate that the original trials were performed with agents that are no longer in use, or on patients without an indication for inotropes, or at a time before automatic cardio-defibrillators were recommended for primary prevention. We conclude that current guidelines for inotropes are misleading in their interpretation of outcomes in patients with advanced heart failure. The guidelines should be revised to adequately reflect the evidence.

Preoperative High Sensitivity C-reactive Protein Level Predicts Early Outcome After Coronary Artery By-pass Surgery

Background: Coronary artery bypass surgery (CABG) with cardioplegia has been considered the gold standard operation for coronary revascularization. Activation of compliments system after CABG surgery involves C-reactive protein (CRP). Patients with preoperative increased CRP levels have significantly higher CRP levels on postoperative days and are at increased risk of developing postoperative complications. High sensitivity CRP ( hs-CRP ) is lower concentration of CRP measured by the hs-CRP test. It is more sensitive and more useful in predicting the potential risk level for cardiovascular disease, heart attacks and strokes. Objective: To assess the association of preoperative hs-CRP level with the incidence of postoperative arrhythmia, low output syndrome and sternal wound infection following on pump CABG surgery. Materials & Methods: The study was cross sectional analytical study. A total of 70 patients were selected. For the purpose of analysis the study subjects were divided into two group; Group A patients with preoperative hs-CRP level <3mg/l (n=35) and Group B patients with preoperative hs-CRP level >3mg/l (n=35). The incidence of early outcome- arrhythmia, low output syndrome and sternal wound infection were observed within 30 days of surgical procedure. Results: The incidence of arrhythmia, low output syndrome and sternal wound infection were significantly less in group A than those in group B. Logistic regression analysis showing significant correlation of hs-CRP with arrhythmia, p value is 0.005; with low output syndrome, p value is 0.003 and with sternal wound infection, p value is 0.004. Conclusion: Preoperative hs- CRP is an important determinant of post operative outcome after CABG surgery and might be useful as predictive marker in risk stratification for postoperative complications in patients scheduled for on pump CABG surgery. KYAMC Journal Vol. 9, No.-4, January 2019, Page 153-158

A Snapshot on Myxoma Operation of 62 Patients at National Institute of Cardiovascular Diseases(NICVD), Dhaka, Bangladesh

Background: Intra-cardiac mass, particularly myxoma operation is common at NICVD .Its frequency is about 1-2% among all operations done here. The main aim of this study was to analyze the different aspects of this tumour and its surgery on 62 patients operated over last three years (2015-2017). Methods: It is a retrospective study .The data were collected over a period of 03 years (2015-2017) For this I studied the ward admission register, OT and ICU registers ,ICU flow charts, talked with the respective unit doctors to collect my data. Then the data were analyzed manually and by computer. Results: Age range of the patients were from 7.5 years to 65years with a mean±SD (36.94±13.99). Male and female patient ratio were M:F=1:1.81.Myxoma were more common in the 4th and 5th decade of life in this study population .Preoperative time delay for operation after hospital admission was 9±2.12days.All the operations were done as an elective procedure rather urgent or emergency procedure. Post operative mortality was around 12.90% among these patients. The causes of high mortality following myxoma operation were Low Output Syndrome, Congestive Heart Failure , Cerebral stroke and septicaemia. Conclusion: Myxoma operation is common in NICVD. Most of our patients were dealt as a routine procedure. Their features and surgical procedure were similar with a little difference among the neighbouring countries. Our post operative outcome was a little bit worse (12.90% mortality) over the mentioned period. We need to find out the causes and to take care of these patients to reduce mortality in future. Bangladesh Heart Journal 2018; 33(2) : 85-89

Esmolol for the treatment of recurrent ventricular tachycardia

Cardiac arrest and electrical storm are two major emergencies. The use of beta blockers in these clinical conditions has been proposed however, definite data about the emergency use of beta blockers in recurrent ventricular tachycardia with pulse have never been published. We report two cases of recurrent ventricular tachycardia which were unresponsive to the standard pharmacological treatment but successfully responsive to esmolol infusion. Both cases showed a reduced left ventricle ejection fraction due to an acute myocardial infarction and to an idiopathic dilated cardiomyopathy respectively. Nevertheless, the use of esmolol was shown to be both safe and effective without inducing low output syndrome.