‘PARAMEDIC-2: Big study,small result’

The PARAMEDIC-2 trial demonstrated that the use of adrenaline compared with placebo in out-of-hospital cardiac arrest (OHCA) resulted in a small increase in 30-day survival, but was associated with a higher number of survivors with severe neurological impairment. These findings received a lot of attention, and generated a widespread discussion about the role of adrenaline in cardiac arrest. In this point of view, we aim to place the PARAMEDIC-2 results in the right perspective by comparing the relative effect of adrenaline to other determinants of cerebral blood flow.

     

A two-entropies analysis to identify functional positions in the transmembrane region of class A G protein-coupled receptors

Residues in the transmembrane region of G protein-coupled receptors (GPCRs) are important for ligand binding and activation, but the function of individual positions is poorly understood. Using a sequence alignment of class A GPCRs (grouped in subfamilies), we propose a so-called "two-entropies analysis" to determine the potential role of individual positions in the transmembrane region of class A GPCRs. In our approach, such positions appear scattered, while largely clustered according to their biological function. Our method appears superior when compared to other bioinformatics approaches, such as the evolutionary trace method, entropy-variability plot, and correlated mutation analysis, both qualitatively and quantitatively.     

Pregnancy-related myocardial infarction

Introduction

The risk of acute myocardial infarction in young women is low, but increases during pregnancy due to the physiological changes in pregnancy, including hypercoagulability. Ischaemic heart disease during pregnancy is not only associated with increased maternal morbidity and mortality, but also with high neonatal complications. Advancing maternal age and other risk factors for cardiovascular diseases may further increase the risk of ischaemic heart disease in young women.

Methods

We searched the coronary angiography database of a Dutch teaching hospital to identify women with acute myocardial infarction who presented during pregnancy or postpartum between 2011 and 2013.

Results

We found two cases. Both women were in their early thirties and both suffered from myocardial infarction in the postpartum period. Acute myocardial infarction was due to coronary stenotic occlusion in one patient and due to coronary artery dissection in the other patient. Coronary artery dissection is a relatively frequent cause of myocardial infarction during pregnancy. Both women were treated by percutaneous coronary intervention and survived.

Conclusion

Physicians should be aware of the increased risk of myocardial infarction when encountering pregnant or postpartum women presenting with chest pain.

     

Ischaemic heart disease during pregnancy or post-partum: systematic review and case series

The risk of manifestations of ischaemic heart disease (IHD) in fertile women is elevated during pregnancy and the post-partum period. With increasing maternal age and a higher prevalence of cardiac risk factors, the incidence of IHD during pregnancy is rising. However, information in the literature is scarce. We therefore performed a retrospective cohort study and systematically reviewed the overall (1975–2013) and contemporary (2005–2013) literature concerning IHD presenting during pregnancy or in the post-partum period. We report two cases of IHD with atypical presentation during pregnancy or post-partum. In our review, we describe 146 pregnancies, including 57 contemporary cases (2005–2013). Risk factors for IHD were present in 80 %. Of the cases of IHD, 71 % manifested in the third trimester or the post-partum period, and 95 % presented with chest pain. The main cause was coronary dissection (35 %), or thrombus/emboli (35 %) in the more contemporary group. Maternal mortality was 8 % (6 % in the contemporary group), and the main cardiac complication was ventricular tachycardia (n = 17). Premature delivery rate was 56 %, and caesarean section was performed in 57 %. Perinatal mortality was 4 %. In conclusion, IHD during pregnancy or in the post-partum period has high maternal mortality and morbidity rates. Also, premature delivery and perinatal mortality rates are high.

Electronic supplementary material

The online version of this chapter (doi:10.1007/s12471-015-0677-6) contains supplementary material, which is available to authorized users.     

Additive value of dobutamine stress echocardiography in patients with an anomalous origin of a coronary artery

An anomalous origin of a coronary artery (AOCA) is the second most common cause of non-traumatic sudden cardiac death in young athletes. Patients with a malignant course of an AOCA of the right coronary artery only need surgical correction when myocardial ischaemia is detected. An AOCA and its malignant or benign course can be detected by coronary angiography, coronary computed tomography or cardiac magnetic resonance imaging. Detection of ischaemia can be more difficult since even a negative maximal-effort stress ECG does not exclude a potential lethal coronary anomaly. Also, there are no case series or trials showing sensitivity or specificity for any form of ischaemia detection for AOCA in the literature. Although not described previously in adults, dobutamine stress echocardiography was previously described in a paediatric population with AOCA. We are the first to describe ischaemia detection by dobutamine stress echocardiography in three adult patients with an AOCA of the right coronary artery who were subsequently referred for surgery.

Electronic supplementary material

The online version of this article (doi: 10.1007/s12471-014-0648-3) contains supplementary material, which is available to authorized users.     

Left bundle,right diagnosis

Netherlands Heart Journal -     

Methodology for the development of a drug library based upon collision-induced fragmentation for the identification of toxicologically relevant drugs in plasma samples

The possibility of creating a robust mass spectral library with use of high-performance liquid chromatography–atmospheric pressure–electrospray ionization (HPLC–AP–ESI) for the identification of drugs misused in cases of clinical toxicology has been examined. Factors reported as influencing the fragmentation induced by “source transport region collision induced dissociation” (CID) have been tested in this study (i.e. solvent, pH, different acids or buffer salts and their concentration, different organic modifiers and the modifier concentration). The tests performed on a few “model drugs” were analysed with use of two different single quadrupole instruments. The large number of mass spectra obtained appears to be affected by the mobile phase conditions to only a minor extent. This also holds for the mass spectra obtained at two different instruments (laboratories). Subsequently breakdown curves have been measured for about 20 randomly chosen drugs by variation of the kinetic energy of their ions in the CID zone through changing the fragmenter voltage. These breakdown curves were used to optimize the fragmenter voltage for each drug. The optimized fragmenter voltages were then applied by use of a variably ramped fragmenter voltage to acquire mass spectra for the library. The chromatographic separations were run on a Zorbax Stable bond column using a 10-mM ammonium formate–acetonitrile gradient method. Spiked blank serum and patient samples with a total of 40 different drugs were extracted with use of a standard basic liquid–liquid extraction (LLE) method. A search of significant peaks in the chromatogram by application of the developed mass spectral library is shown to result in a more than 95% positive identification.