18 research outputs found
Sacubitril/valsartan in COVID-19 patients: the need for trials
We thank Luigi Petramala and Claudio Letizia
for their comment1 on our letter about the
possible role of sacubitril/valsartan in patients
with coronavirus disease 2019 (COVID-19).2
The authors rightly affirm the need for continuing previous therapies with angiotensinconverting enzyme inhibitors (ACE-Is) or sartans in patients with COVID-19, as outlined by
recent international consensus papers.3 There
is no definite evidence about the harmful or
protective use of ACE-Is/sartans in COVID-19
patients.4,5 Dedicated, randomized controlled
trials are needed in order to verify the possible
worsening of lung infection and/or systemic involvement in patients with COVID-19 who are
chronically treated with ACE-Is/sartans.
Furthermore, we do not intend to pressurize
the indiscriminate change of previous treatments towards sacubitril/valsartan in the absence of evidence from randomized trials. The
COVID-19 pandemic forced the scientific community to think about possible, alternative solutions to counteract the multiorgan damage by
the virus.
We do agree that interrupting specific treatments would increase adverse clinical outcomes in patients, independently from the
course of COVID-19, but trying to improve
therapeutic solutions is challenging. Sacubitril/
valsartan has already demonstrated superiority
over standard therapies in patients suffering
from heart failure with reduced ejection fraction (HFrEF), regardless of any comorbidities.6
Moreover, post-hoc analysis from the
Comparison of Sacubitril-Valsartan versus
Enalapril on Effect on NT-proBNP in Patients
Stabilized from an Acute Heart Failure Episode
(PIONEER-HF) trial revealed a 42% relative risk
reduction in the composite endpoint of death
from any cause, re-hospitalization for heart failure, left ventricular assist device implantation,
or listing for cardiac transplant, a 42% relative
risk reduction in the composite endpoint of
cardiovascular death or re-hospitalization for
heart failure, and a 39% relative risk reduction
in re-hospitalization for heart failure after 8
weeks of treatment with sacubitril/valsartan
administered early in patients stabilized during
hospitalization for acute decompensated heart
failure.7 Furthermore, a significant 50% reduction in NT-proBNP is evident after the first
week of treatment with sacubitril/valsartan.8
The need for early administration of sacubitril/valsartan in acute heart failure is probably
becoming mandatory in pharmacological management of heart failure patients, although not
yet covered by the guidelines.
In recent days, the characteristics of cardiac
injury during COVID-19 infection have been
made available to the medical and scientific
community.9,10 In COVID-19 patients, with and
without symptoms attributable to pneumonia,
there is evidence of a significant increase in NTproBNP, regardless of left ventricular dysfunction. NT-proBNP levels are also the results of
acute renal injury and pro-inflammatory molecules such as interleukin-1 and C-reactive protein, which are independent of cardiac function.
Shi et al. showed that patients with cardiac injury had a higher rate of mortality during the
interval both from symptom onset to admission
and from admission to clinical endpoint.
Increased death rates were associated with
higher levels of NT-proBNP. 9 Gao et al.
reported that higher NT-proBNP was an independent risk factor for in-hospital death in
patients with severe COVID-19 after adjusting
for sex, age, hypertension, coronary heart disease, chronic obstructive pulmonary disease,
myoglobin, creatin kinase-MB, high sensitivity
troponin-I, white blood cell count, lymphocyte
count, C-reactive protein, and procalcitonin.10
Based on the evidence and in relation to the
hypotheses generated from our previous correspondence,2 we thought about the possibility
of early adoption of sacubitril/valsartan in
patients with COVID-19, to maximize the antiinflammatory effects of an enhanced natriuretic
peptide system and contain the effects of angiotensin II. Clinical trials in COVID-19 patients
are needed in order to validate our hypothesis
DIC-Like Syndrome Following Administration of ChAdOx1 nCov-19 Vaccination
In recent weeks, adverse reactions have been reported after administration of Oxford–AstraZeneca chimpanzee adenovirus vectored vaccine ChAdOx1 nCoV-19 (AZD1222), in particular thrombus formation, which has led several European Countries to discontinue administration of this vaccine. On March 8, 2021, the European Medicines Agency Safety Committee did not confirm this probable association. We report the case of a patient who developed disseminated intravascular coagulation after the first dose of Oxford-Astra Zeneca vaccine, which resolved in a few days with the administration of dexamethasone and enoxaparin. This work demonstrates the safety of the Oxford-Astra Zeneca vaccine and that any development of side effects can be easily managed with a prompt diagnosis and in a short time with a few commonly used drugs
Telogen effluvium treated with Serenoa repens supplement
Telogen effluvium is a non-scarring form of hair loss. Clinically, the disease is characterized by hair loss where more than normalamounts of hair fall out; it usually affects the whole scalp in a widespread manner. When hair loss is very pronounced and persists fora long time, alopecia becomes clinically evident. It is not associated to subjective symptoms. In this paper, the authors describe theclinical case of a 67-year old patient suffering from telogen effluvium, treated with a supplement containing amino acids (L-cystineand L-methionine), vitamin E, iron and extract of Serenoa repens
Migraine and lifestyle in childhood
Migraine is one of the most frequently reported somatic complaints in childhood, with a negative impact on health-related quality of life. The incidence of migraine in childhood has substantially increased over the past 30 years, probably due to both increased awareness of the disease and lifestyle changes in this age group. Indeed, several conditions have been identified as risk factors for migraine in childhood. Amongst these, dysfunctional family situation, the regular consumption of alcohol, caffeine ingestion, low level of physical activity, physical or emotional abuse, bullying by peers, unfair treatment in school and insufficient leisure time seem to play a critical role. Nevertheless, there are only few studies about the association between migraine and lifestyle in childhood, due to previous observations specifically focused on "headache" in children. In this brief review, we will concentrate upon recent studies aimed to explore migraine and lifestyle risk factors in childhood
Impaired Vagal Activity in Long-COVID-19 Patients
Long-COVID-19 refers to the signs and symptoms that continue or develop after the “acute COVID-19” phase. These patients have an increased risk of multiorgan dysfunction, readmission, and mortality. In Long-COVID-19 patients, it is possible to detect a persistent increase in D-Dimer, NT-ProBNP, and autonomic nervous system dysfunction. To verify the dysautonomia hypothesis in Long-COVID-19 patients, we studied heart rate variability using 12-lead 24-h ECG monitoring in 30 Long-COVID-19 patients and 20 No-COVID patients. Power spectral analysis of heart rate variability was lower in Long-COVID-19 patients both for total power (7.46 ± 0.5 vs. 8.08 ± 0.6; p p p = 0.015; Cohens-d = 0.76) components. The LF/HF ratio was significantly higher in Long-COVID-19 patients (1.46 ± 0.27 vs. 1.23 ± 0.13; p = 0.001; Cohens-d = 1.09). On multivariable analysis, Long-COVID-19 is significantly correlated with D-dimer (standardized β-coefficient = 0.259), NT-ProBNP (standardized β-coefficient = 0.281), HF component of spectral analysis (standardized β-coefficient = 0.696), and LF/HF ratio (standardized β-coefficient = 0.820). Dysautonomia may explain the persistent symptoms in Long COVID-19 patients. The persistence of a procoagulative state and an elevated myocardial strain could explain vagal impairment in these patients. In Long-COVID-19 patients, impaired vagal activity, persistent increases of NT-ProBNP, and a prothrombotic state require careful monitoring and appropriate intervention
Pathological evidence of adrenergic cardiac denervation in a patient with congestive heart failure
Exercise training effects on elderly and middle-age patients with chronic heart failure after acute decompensation: A randomized, controlled trial
Abstract
Background
The aim of this study was to evaluate the effect of exercise training on cardiac function in heart failure (HF) patients recently suffering from acute decompensation. Radionuclide ambulatory ventricular function monitoring (VEST) was used to detect variations in cardiac hemodynamics during training period.
Methods
This was a monocentric, randomized, controlled trial. We enrolled 72 HF patients [left ventricle ejection fraction (LVEF) < 40%] within two weeks after acute cardiogenic pulmonary edema: 40 in the elderly group, 32 in the middle-aged group. Trained patients underwent a specific four-weeks exercise program (closed-chain resistive activities and abdominal exercises) which was supervised by a therapist in agreement with patients' characteristics. Catecholamines at rest, echocardiography, right-heart catheterization, and bicycle ergometer were performed. VEST was performed at the end of the 4 weeks-training in all patients in order to assess patients' cardiac hemodynamics [LVEF, cardiac output (CO), stroke volume].
Results
Exercise training significantly improved exercise duration, peak oxygen consumption, and ventilatory threshold both in elderly and middle-aged patients (p < 0.0001) after the 4-week controlled training. Despite age (F = 35.086, p < 0.0001; F = 16.967, p < 0.0001; F = 42.574, p = 0.03, respectively), training reliably influence previous cardiopulmonary parameters (F = 29.402, F = 16.421, F = 26.80, p < 0.0001, respectively). Norepinephrine and epinephrine were significantly reduced in both trained groups. Peak LVEF (37.3 ± 4.7% vs 34 ± 6.2%, p = 0.002), peak stroke volume (43.3 ± 3.9% vs 37.5 ± 4.3%, p = 0.001), and peak CO (63.4 ± 6.1% vs 48.2 ± 4.7%, p < 0.0001) increased in middle-aged patients after 4-week training.
Conclusions
Exercise training improves cardiac performance indexes and pulmonary function in both middle-aged and elderly HF patients early after an acute episode of cardiac decompensation
Safety and Feasibility of Treatment with Rivaroxaban for Non-Canonical Indications: A Case Series Analysis.
Abstract
BACKGROUND AND OBJECTIVES:
The new oral anticoagulants (NOACs) are used for the prevention of thromboembolic complications in patients with non-valvular atrial fibrillation (AF) and those at risk of deep venous thrombosis. Their rapid onset of action and predictable pharmacokinetic and pharmacodynamic profiles make them the optimal alternative to warfarin in the treatment of these two categories of patients. Unfortunately, however, NOACs cannot be used in patients with valvular AF or valvular cardiac prostheses. Although mechanical valves are effectively a contraindication to NOAC use due to several pathophysiological mechanisms that promote the use of warfarin rather than NOACs, few data exist regarding the use of such new pharmacological compounds on patients with cardiac biological valves or those who have undergone mitral repair or tubular aortic graft implantation.
METHODS:
Our case series involved 27 patients [mean age 70 ± 10 years; mean CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years (doubled), Diabetes mellitus, Stroke/transient ischemic attack (doubled), Vascular disease, Age 65-74 years, Sex category): 6 ± 1.4; and mean HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalized ratios, Elderly, Drugs or alcohol): 4 ± 1] with AF and biological prostheses, repaired mitral valves, or tubular aortic graft who were treated with the factor Xa inhibitor rivaroxaban due to inefficacy or adverse effects of warfarin.
RESULTS:
The mean left ventricular ejection fraction was 48 ± 9 %, the left atrial diameter was 46.5 ± 7 mm, and the estimated glomerular filtration rate was 45 ± 21 mL/min/1.73 m2. The mean duration of treatment was 15 ± 2 months. No relevant complications or recurrent thromboembolic events occurred. Three patients had recurrent nose bleeding and two had hematuria that led to reduction of the rivaroxaban dose by the treating physician to 15 mg once a day after 4 months of therapy. No further bleeding episode was recorded after escalating the dose.
CONCLUSIONS:
Rivaroxaban is a valuable treatment option for patients with biological prostheses, repaired mitral valves, or a tubular aortic graft in order to prevent thromboembolic complications
Therapeutic strategies in migraine patients with mood and anxiety disorders: physiopathological basis
Additional file 1: of Relative lymphocyte count as an indicator of 3-year mortality in elderly people with severe COPD
Table S1. Evaluation of the reproducibility of measurements during the follow-up period. (DOCX 17 kb