Left ventricular dysfunction, acute

OXYMORPHONE HYDROCHLORIDE Relief of moderate to severe pain. Parenterally for preoperative medication, support of anesthesia, obstetrical analgesia, and for relief of anxiety in patients with dyspnea associated with pulmonary edema secondary to acute left ventricular dysfunction. 

Phosphodiesterase III inhibitors are very useful in combination with a pi-adrenoceptor agonist in the treatment of acute left ventricular dysfunction. The pi agonist increases the intracellular cAMP by activation of adenylyl cyclase, while the phosphodiesterase III inhibitor prevents degradation of cAMP. The combined effects are additive and may be synergistic in the failing myocardium. 

Overdose is common amongst users (up to 22% of heavy users report losing consciousness). The desired euphoria and excitement turns to acute fear, with psychotic symptoms, convulsions, hypertension, haemorrhagic storke, tachycardia, arrhythmias, hyperthermia coronary vasospasm (sufficient to present as the acute coronary syndrome with chest pain and myocardial infarction) may occur, and acute left ventricular dysfunction. Treatment is chosen according to the clinical picture (and the known mode of action), from amongst, e.g. haloperidol (rather than chlorpromazine) for mental disturbance diazepam for convulsions a vasodilator, e.g. a calcium channel blocker, for hypertension glyceryl trinitrate for myocardial ischaemia (but not a p-... 

Eplerenone has been shown recently to reduce morbidity and mortality in patients soon after experiencing an acute myocardial infarction (within 3 to 14 days). However, this supporting evidence was in patients with symptoms of acute left ventricular dysfunction (systolic heart failure). Considering that this drug has a propensity to cause significant hyperkalemia, and given the patient population studied, eplerenone should be used only in selected patients following a myocardial infarction. 

Srikanth S, Barua R, Ambrose J. Meth-amphetamine-associated acute left ventricular dysfunction a variant of stress-induced cardiomyopathy. Cardiology 2008 109 188-92. 

Lemaire F, Teboul JL, Cinotti L, et aL Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology 1988 69 171—179. 

Concomitant use of calcium channel blockers (atenolol) Bradycardia and heart block can occur and the left ventricular end diastolic pressure can rise when beta-blockers are administered with verapamil or diltiazem. Patients with preexisting conduction abnormalities or left ventricular dysfunction are particularly susceptible. Recent acute Ml (sotalol) Sotalol can be used safely and effectively in the long-term treatment of life-threatening ventricular arrhythmias following an Ml. However, experience in the use of sotalol to treat cardiac arrhythmias in the early phase of recovery from acute Ml is limited and at least at high initial doses is not reassuring. 

Left ventricular dysfunction (LVD) following Ml To reduce cardiovascular mortality in clinically stable patients who have survived the acute phase of a Ml and have a left ventricular ejection fraction of 40% or less (with or without symptomatic heart failure). 

Nishimura RA, Hayes DL, Holmes DR, Jr., Tajik AJ. Mechanism of hemodynamic improvement by dualchamber pacing for severe left ventricular dysfunction an acute Doppler and catheterization hemodynamic study. J. Am. Coll. Cardiol. 1995 25 281-8. 

Nitrates are required for symptomatic relief of chest pain they are not proven to improve hard outcomes such as MI or death. Nitrates should be given initially sublingually or by spray, followed by oral or transdermal routes if pain is relieved. Lack of pain relief mandates i.v. administration. Beta-blockers such as metoprolol are used and may reduce the risk of subsequent MI. Calcium channel blockers such as dilfiazem, verapamil, or long-acting di-hydropyridines can be added for symptom control if nitrates and beta-blockers do not suffice they do not improve outcomes. In fact, they may worsen outcomes in the presence of left ventricular dysfunction or CHF in acute coronary syndrome. 

Abbreviations. AIRE, acute Infarction ramipril efficacy CONSENSUS, cooperative north Scandinavian enalapril sur/f/a study HF, heart failure LVEF, left ventricular ejection fraction NYHA. New York Heart Association SAVE, survival and ventricular enlargement SMILE, survival of myocardial infarction long-term evaluation SOLVD. studies of left ventricular dysfunction TRACE, trandolapril cardiac evaluation study group. 

Pitt B, Remme W, Zannad F et al. The Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003 348 1309-1321. 

Pedersen OD, Bagger H, Kober L, Torp-Pedersen C. Trandolapril reduces the incidence of atrial fibrillation after acute myocardial infarction in patients with left ventricular dysfunction. Circulation 1999 100 376-380. 

In the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS), in 6632 patients with an acute myocardial infarction complicated by left ventricular dysfunction and heart failure, the addition of eplerenone 25-50 mg/day to optimal medical therapy significantly reduced all-cause mortality by 15% and cardiovascular mortality by 17% over a mean follow-up period of 16 months hospitalization rates were also reduced (29). 

Danish Investigations of Arrhythmia and Mortality ON Dofetilide. Dofetilide in patients with left ventricular dysfunction and either heart failure or acute myocardial infarction rationale, design, and patient characteristics of the DIAMOND studies. Clin Cardiol 1997 20(8) 704-10. 

Acute dilated cardiomyopathy with left ventricular dysfunction related temporally to fluorouracil and cisplatin infusion, with subsequent complete recovery, has been tentatively linked to fluorouracil (19). Other similar events have been reported (20,21). The association is more striking in patients who receive a continuous infusion of fluorouracil and in patients who receive concomitant cisplatin (22,23). For example, myocardial ischemia and infarction occur in about 10% of patients who receive fluorouracil by infusion and sudden death has occurred (24). 

There have been several case reports that high doses of nitric oxide (40-80 ppm) reduce pulmonary vascular resistance and increase pulmonary capillary wedge pressure in some patients with left ventricular dysfunction. The acute increase in left ventricular filling pressure that ensues can cause or exacerbate pulmonary edema. The author concluded that in patients with severe left ventricular dysfunction (pulmonary capillary wedge pressure over 25 mmHg) it would be prudent to avoid the use of inhaled nitric oxide. 

A beneficial effect of thyroid hormone on left ventricular remodeling is also reported. In an experimental model of acute myocardial infarction in rats, a decline in serum T3 was observed associated with left ventricular dysfunction and changes in T3 responsive genes. Treatment with high doses of T3 for three weeks resulted in improved cardiac function with normalization of most of the changes in gene expression.89 Similarly, administration of DITPA (a thyroid analogue) after myocardial infarction in rabbits was associated with improved cardiac function.90... 

Kurisu S, Sato H, Kawagoe T et al. Tako-tsubo-like left ventricular dysfunction with ST-segment elevation a novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J 2002 143 448. 

The Valsartan in Acute Myocardial Infarction Trial (VALIANT) compared the effects of valsartan, captopril, and the combination of the two agents in post-MI patients with symptomatic heart failure, left ventricular dysfunction, or both. The primary end point of total mortality occurred in 19.3% of patients receiving valsartan and captopril, 19.5% of captopril-treated patients, and 19.9% of the valsartan-treated group. Thus, in this high-risk post-MI population, valsartan was as effective as captopril in reducing the risk of death, but combination therapy only increased the risk of adverse effects and did not improve survival compared with monotherapy with either agent. 

The development of a bedside assay for plasma BNP has focused considerable attention on the use of BNP as an aid in the diagnosis of suspected heart failure. Plasma BNP concentration is positively correlated with the degree of left ventricular dysfunction and heart failure, and this assay is now used frequently in acute care settings to assist in the differential diagnosis of dyspnea [heart failure versus asthma, chronic obstructive pulmonary disease (COPD), or infection]. Recent studies found that an elevated BNP concentration is an independent predictor of heart failure as the cause of dyspnea and that in patients with decompensated heart failure, an elevated pre-hospital discharge BNP concentration is associated with an increased risk of death or readmission. Additional research is ongoing to better characterize the role of BNP measurement in the diagnosis and treatment of heart failure. 

In addition to the clinical presentation, invasive hemodynamic monitoring helps in the selection of appropriate medical therapy, as well as in the classification of patients into specific subsets. These hemodynamic subsets were first proposed for patients with left ventricular dysfunction following an acute MI but also are applicable... 

Nikolaidis LA, Mankad S, Sokos GG, Miske G, Shah A, Elahi D, et al. Effects of glucagon-like peptide-1 in patients with acute myocardial infarction and left ventricular dysfunction after successful reperfusion. Circulation 2004 109 962-965. [Epub 2004 Feb 23.]... 

TRACE 1749 patients with left ventricular dysfunction after acute Ml Not reported Trandolapril 1 to 4 mg daily 24 to 50 months Trend towards greater benefit of trandolapril in those receiving aspirin (mortality of 45% with ACE inhibitor, and 34% with ACE inhibitor plus aspirin). 12... 

Meta anal) is of AIRE, HOPE, SAVE, SOLVD, and TRACE 22060 patients with either left ventricular d) unction or heart failure without Ml, coronary artery disease without left ventricular dysfunction, or acute Ml Not reported Captopril, enalapril, ramipril, trandolapril More than 3 years Benefits of ACE inhibitors observed even if aspirin givea 14... 

The electrophysiology test may be useful for specific clinical situations. The electrophysiology test may be useful for patients with wide complex tachycardia of unclear mechanism (76) and for patients with syncope and impaired left ventricular function or structural heart disease (76). Examples include a patient with left ventricular dysfunction and a recent non-Q-wave myocardial infarction who has suffered a sustained arrhythmia near the time of the acute myocardial infarction and a patient who has a cardiac arrest after cardiac surgery, in the throes of acute congestive heart failure, or during infusion of an inotropic drug. 

McMurray, J., et al., Antiarrhythmic effect of carvedilol after acute myocardial infarction results of the Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction (CAPRICORN) Trial. J Am Coll Cardiol, 2005. 45(4) p. 525-30. 

El-Shitany NA, Tolba OA, El-Shanshory MR, El-Hawary EE. Protective effect of carvedilol on adriamycin-induced left ventricular dysfunction in children with acute lymphoblastic leukemia. J Card Fail 2012 18(8) 607-13. 

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