Cardiac risk

From Rosen RQ Jackson C, Kostis JB. Erectile dysfunction and cardiac disease Recommendations of the Second Princeton Conference Curr Urol Rep 2006 7 490-496 and Kostis JB, Jackson C, Rosen R et al Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference). Am J Cardiol 2005 96 313-321. 

Cushman M, Costantino JP, Tracy RP, Song K, Buckley L, Roberts JD, Krag DN (2001) Tamoxifen and cardiac risk factors in healthy women suggestion of an antiinflammatory effect. Arterioscler Thromb Vase Biol 21 255-261... 

Myocardial toxicity, manifested in its most severe form by potentially fatal CHF, may occur either during therapy with mitoxantrone or months to years after termination of therapy. Mitoxantrone use has been associated with cardiotoxicity this risk increases with cumulative dose. In cancer patients, the risk of symptomatic CHF was estimated to be 2.6% for patients receiving up to a cumulative dose of 140 mg/m. For this reason, monitor patients for evidence of cardiac toxicity and question them about symptoms of heart failure prior to initiation of treatment. Monitor patients with multiple sclerosis (MS) who reach a cumulative dose of 100 mg/m for evidence of cardiac toxicity prior to each subsequent dose. Ordinarily, patients with MS should not receive a cumulative dose greater than 140 mg/m. Active or dormant cardiovascular disease, prior or concomitant radiotherapy to the mediastinal/pericardial area, previous therapy with other anthracyclines or anthracenediones, or concomitant use of other cardiotoxic drugs may increase the risk of cardiac toxicity. Cardiac toxicity with mitoxantrone may occur at lower cumulative doses whether or not cardiac risk factors are present (see Warnings and Administration.and.Dosage). 

Uses CAD, hypercholest olemia, hypertriglyceridemia, type 2 DM, arthritis Efficacy No definitive data on X cardiac risk in general population may X lipids and help w/ secondary MI prevention Dose One FDA approved (Lovaza) OTC 1500-3000 mg/d Ammcan Heart Association recommends 1 g/d Caution Mct-cury contamination possible, some studies suggest t cardiac events SE t Bleed risk, dyspqjsia, belching, aftertaste Interactions Anticoagulants EMS t Effects of anticoagulants... 

Christ, T., Wettwer, E., Wuest, M., Braeter, M., Donath, E., Champeroux, P., Richard, S. and Ravens, U. (2008) Electrophysiological profile of propiverine - relationship to cardiac risk. Naunyn-Schmiedebergs Archives of Pharmacology, 376, 431 40. 

Other potential adverse events are rash, fever, nausea, vomiting, diarrhea, headache, dyspnea, fatigue, and pancreatitis (rare). Abacavir should be used cautiously in patients with existing cardiac risk factors due to a possible increased risk of myocardial events. 

Sulprostone should be used with care, particularly in patients with cardiac risk factors, and only in settings equipped to manage complications. 

Verrier RL, Mittleman MA. Sleep-related cardiac risk. In Kryger MH, Roth T, Dement WC, eds, Principles and Practice of Sleep Medicine. Philadelphia Saunders, 2000 997-1013. 

There is no evidence that treating ED in patients with cardiovascular disease increases cardiac risk however, this is with the proviso that the patient is properly assessed and the couple or individual (self-stimulation may be the only form of sexual activity) are appropriately counselled. Oral drug therapy is the most widely used because of its acceptability and effectiveness, but all therapies have a place in management. The philosophy is to always be positive during what, for many men and their partners, is an uncertain time. 

ED is common in patients with cardiovascular disease and should be routinely enquired about. The cardiac risk of sexual activity in patients with cardiovascular disease is minimal in properly assessed patients. The restoration of a sexual relationship is a possibility for the majority of patients with cardiovascular disease and ED using oral PDE5 inhibitors, which have an excellent safety profile (avoiding nitrate use). ED is a marker for cardiovascular disease as well as its consequence therefore, its identification (in the asymptomatic male) provides the opportunity to address other cardiovascular risk factors and detect silent but significant vascular pathology. 

Jackson G, Rosen RC, Kloner RA, etal. The second Princeton consensus on sexual dysfunction and cardiac risk new guidelines for sexual medicine. J Sex Med 2006 3 28-36. 

Straznicky NE, Lambert EA, Lambert GW, Masuo K, Esler MD, Nestle PJ. Effects of dietary weight loss on sympathetic activity and cardiac risk factors associated with the metabolic syndrome. J. Clin. Endocrinol. Metab. 2005 90 5998-6005. 

Post-MI management calls for strict adherence to a program of secondary prevention. Cardiac risk factors have to be excluded or modified, for instance, by reduction of overweight, cessation of smoking, optimal control of diabetes mellitus, and physical exercise (a dog that loves to run is an ideal training partner). Supportive pharmacother-apeutic measures include administration of platelet aggregation inhibitors, p-blockers, and ACE inhibitors. 

The cardiac risk program (actually an Excel spreadsheet) and risk assessment charts can be downloaded from the BHS website at http //www.hyp.ac.uk/bhsinfo. They may also be found in the British National Formulary. 

Reduction of portal pressure. Vasopressin (anti-duiretic hormone, see p. 711), in addition to its action on the renal collecting ducts (through receptors), constricts smooth muscle (Vj receptors) in the cardiovascular system (hence its name), and particularly in splanchnic blood vessels, so reducing blood flow in the portal venous system. Unfortunately, coronary vasoconstriction can also occur, and treatment has to be withdrawn from 20% of patients because of myocardial ischaemia. Glyceryl trinitrate (transdermally, sublingually, or intravenously) reduces the cardiac risk and, advantageously, further reduces portal venous resistance and pressure. 

B. N. Becker, J. Himmelfarb, W. L. Henrich and R. M. Hakim, Reassessing the Cardiac Risk Profile in Chronic Hemodialysis Patients A Hypothesis on the Role of Oxidant Stress and Other Non-Traditional Cardiac Risk Factors, Journal ofAmerican Society of Nephrology 8 (1997) 475-486. 

In a study of the interaction of emedastine difumarate 4 mg bd with ketoconazole 200 mg bd in 12 subjects there was a moderate but statistically significant interaction however, there was no increase in the QT . interval during concomitant therapy (3). The authors concluded that these findings are consistent with the multiple metabohc pathways that supplement the metabolism of emedastine by different enzymatic isoforms of CYP450, and that concomitant treatment with emedastine and ketoconazole in people with normal QT intervals can be undertaken without special precautions. However, it is difficult to determine the precise cardiac risk, if any, posed by the administration of emedastine eye-drops (4). 

Moxifloxacin new preparation. A me-too with more cardiac risks. Prescrire Int 2002 ll(62) 168-9. 

Anonymous. Nicotine patches and chewing gum-cardiac risks with concomitant smoking. WHO Newslett 1996 5,6 6. 

Continuous cardiac monitoring is recommended for patients with serious conduction abnormalities however, routine cardiac monitoring is considered unnecessary in patients without a history of cardiac conduction abnormalities (7). Further studies are needed to determine the risk in patients treated with paclitaxel with predisposing cardiac risk factors. 

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