Early recognition of abdominal compartment syndrome in patients with acute pancreatitis

AIM： To assess the value of widely used clinical scores in the early identification of acute pancreatitis （AP） patients who are likely to suffer from intra-abdominal hypertension （IAH） and abdominal compartment syndrome （ACS）.
METHODS： Patients （η = 44） with AP recruited in this study were divided into two groups （ACS and non-ACS） according to intra-abdominal pressure （IAP） determined by indirect measurement using the transvesical route via Foley bladder catheter. On admission and at regular intervals, the severity of the AP and presence of organ dysfunction were assessed utilizing different multifactorial prognostic systems： Glasgow-Imrie score, Acute Physiology and Chronic Health Evaluation Ⅱ （APACHE-Ⅱ） score, and Multiorgan Dysfunction Score （MODS）. The diagnostic performance of scores predicting ACS development, cut-off values and specificity and sensitivity were established using receiver operating characteristic （ROC） curve analysis.
RESULTS： The incidence of ACS in our study population was 19.35%. IAP at admission in the ACS group was 22.0 （18.5-25.0） mmHg and 9.25 （3.0-12.4） mmHg in the non-ACS group （P 〈 0.01）. Univariate statistical analysis revealed that patients in the ACS group had significantly higher multifactorial clinical scores （APACHE Ⅱ, Glasgow-Imrie and MODS） on admission and higher maximal scores during hospitalization （P 〈 0.01）. ROC curve analysis revealed that APACHE Ⅱ, Glasgow-Imrie, and MODS are valuable tools for early prediction of ACS with high sensitivity and specificity, and that cut-off values are similar to those used for stratification of patients with severe acute pancreatitis （SAP）.
CONCLUSION： IAH and ACS are rare findings in patients with mild AR Based on the results of our study we recommend measuring the IAP in cases when patients present with SAP （APACHE Ⅱ 〉 7; MODS 〉 2 or Glasgow-Imrie score 〉 3）.     

Reduction of intra-abdominal pressure after percutaneous catheter drainage of pancreatic fluid collection predicts survival

ObjectiveIntra-abdominal hypertension (IAH) can adversely affect the outcome in patients of acute pancreatitis (AP). Effect of percutaneous drainage (PCD) on IAH has not been studied. We studied the effect of PCD on IAH in patients with acute fluid collections.Material and methodsConsecutive patients of AP undergoing PCD between Jan 2016 and May 2018 were evaluated for severity markers, clinical course, hospital and ICU stay, and mortality. Patients were divided into two groups: with IAH and with no IAH (NIAH). The two groups were compared for severity scores, organ failure, hospital and ICU stay, reduction in IAP and mortality.ResultsOf the 105 patients, IAH was present in 48 (45.7%) patients. Patients with IAH had more often severe disease, BISAP ≥2, higher APACHE II scores and computed tomography severity index (CTSI). IAH group had more often OF (87.5% vs. 70.2%, p = 0.033), prolonged ICU stay (12.5 vs. 6.75 days, p = 0.007) and higher mortality (52.1% vs. 15.8%, p < 0.001). After PCD, IAP decreased significantly more in the IAH group (21.85 ± 4.53 mmHg to 12.5 ± 4.42 mmHg) than in the NIAH group (12.68 ± 2.72 mmHg to 8.32 ± 3.18 mmHg), p = <0.001. Reduction of IAP in patients with IAH by >40% at 48 h after PCD was associated with better survival (63.3% vs. 36.7%, p = 0.006).ConclusionWe observed that patients with IAH have poor outcome. PCD decreases IAP and a fall in IAP >40% of baseline value predicts a better outcome after PCD in patients with acute fluid collections.     

Ascites in acute pancreatitis: not a silent bystander

Background & aimAscites in patients with acute pancreatitis (AP) is understudied although recent literature hints at its evident role in the final outcome. This study was planned to study the characteristics of ascites in patients of AP and its effect on the disease course and outcome.MethodsConsecutive patients of AP were studied and patients with or without ascites were evaluated for the baseline parameters and severity assessment. Ascites was quantified and fluid analyzed for its characteristics. Intraabdominal pressure (IAP) was monitored. The various outcome parameters were compared between the two groups of patients with and without ascites.ResultsOf the cohort of 213 patients, 82 (38.5%) developed ascites. Ascites group had significantly higher rates of organ failure (p = 0.001), necrosis (p=<0.001) and higher severity assessment scores. The ascites group had significantly longer hospital and ICU stay and higher ventilator days compared to the non-ascites group. Mortality was also higher in the ascites group (34.1% vs 8.45; p = 0.001). Majority of patients with ascites had moderate to gross ascites (75.6%), low serum ascites albumin gradient (87.8%) with low amylase levels (71.9%). Sub-group analysis in ascites group showed that patients with fatal outcome had higher rates of moderate to gross ascites, higher baseline IAP and lower reduction in IAP after 48 h. Moderate to gross ascites and grades of intra-abdominal hypertension (IAH) were significant predictors of mortality (AUC – 0.76).ConclusionAP patients with ascites have a more severe disease with poorer outcome. Higher degrees of ascites and IAH grades are significant predictors of mortality.     

Current concepts of the role of abdominal compartment syndrome in acute pancreatitis – An opportunity or merely an epiphenomenon

The association of acute pancreatitis (AP) with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) has only recently been recognized. The detrimental effects of raised intra-abdominal pressure in cardiovascular, pulmonary and renal systems have been well established. Although IAH was associated with a higher APACHE II score and multi-organ dysfunction syndrome (MODS) in severe acute pancreatitis, a causal relationship between ACS and MODS in SAP is yet to be established. It is therefore debatable whether IAH is a phenomenon causative of organ failure or an epiphenomenon seen in conjunction with other organ dysfunction. This review systemically examines the pathophysiological basis and clinical relevance of ACS in AP and summarizes all the available evidence in its management.     

Intra-Abdominal Pressure in the Early Phase of Severe Acute Pancreatitis: Canary in a Coal Mine? Results from a Rigorous Validation Protocol

Background/Aims

Intra-abdominal hypertension (IAH) is being increasingly reported in patients with severe acute pancreatitis (SAP) with worsened outcomes. The present study was undertaken to evaluate intra-abdominal pressure (IAP) as a marker of severity in the entire spectrum of acute pancreatitis and to ascertain the relationship between IAP and development of complications in patients with SAP.

Methods

IAP was measured via the transvesical route by measurements performed at admission, once after controlling pain and then every 4 hours. Data were collected on the length of the hospital stay, the development of systemic inflammatory response syndrome (SIRS), multiorgan failure, the extent of necrosis, the presence of infection, pleural effusion, and mortality.

Results

In total, 40 patients were enrolled and followed up for 30 days. The development of IAH was exclusively associated with SAP with an APACHE II score ≥8 and/or persistent SIRS, identifying all patients who were going to develop abdominal compartment syndrome (ACS). The presence of ACS was associated with a significantly increased extent of pancreatic necrosis, multiple organ failure, and mortality. The mean admission IAP value did not differ significantly from the value obtained after pain control or the maximum IAP measured in the first 5 days.

Conclusions

IAH is reliable marker of severe disease, and patients who manifest organ failure, persistent SIRS, or an Acute Physiology and Chronic health Evaluation II score ≥8 should be offered IAP surveillance. Severe pancreatitis is not a homogenous entity.     

Intra-abdominal pressure: Time ripe to revise management guidelines of acute pancreatitis?

AIM: To systematically review evidence on pathophysiology of intra-abdominal pressure(IAP) in acute pancreatitis(AP) with its clinical correlates. METHODS: Systematic review of available evidence in English literature with relevant medical subject heading terms on Pub Med, Medline and Scopus with further search from open access sources on internet as suggested by articles retrieved. RESULTS: Intra-abdominal hypertension(IAH) is increasingly gaining recognition as a point of specific intervention with potential to alter disease outcome and improve mortality in AP. IAH can be expected in at least 17% of patients presenting with diagnosis of AP to a typical tertiary care hospital(prevalence increasing to 50% in those with severe disease). Abdominal compartment syndrome can be expected in at least 15% patients with severe disease. Recent guidelines on management of AP do not acknowledge utility of surveillance for IAP other than those by Japanese Society of Hepato-BiliaryPancreatic Surgery. We further outline pathophysiologic mechanisms of IAH; understanding of which advances our knowledge and helps to coherently align common observed variations in management related conundrums(such as fluid therapy, nutrition and antibiotic prophylaxis) with potential to further individualize treatment in AP. CONCLUSION: We suggest that IAP be given its due place in future practice guidelines and that recommendations be formed with help of a broader panel with inclusion of clinicians experienced in management of IAH.     

Management of intra-abdominal hypertension in patients with severe acute pancreatitis with continuous hemodiafiltration using a polymethyl methacrylate membrane hemofilter

To evaluate, with a prospective observational study, whether continuous hemodiafiltration using a polymethyl methacrylate membrane hemofilter (PMMA-CHDF) is effective for prevention and treatment of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) on patients with severe acute pancreatitis (SAP). The study was carried out in the general intensive care unit (ICU) of a university hospital. Seventeen consecutive patients with SAP were treated in the intensive care unit and underwent PMMA-CHDF whether or not they had renal failure. Blood level of interleukin (IL)-6, as an indicator of cytokine network activation, and intra-abdominal pressure (IAP) were measured daily to investigate their time-course of changes and the correlation between the two. The blood level of IL-6 was high at 1350+/-1540 pg/mL on admission to the ICU. However, it significantly decreased to 679+/-594 pg/mL 24 h after initiation of PMMA-CHDF (P<0.05), and thereafter decreased rapidly. Mean intra-abdominal pressure (IAP) on admission was high, at 14.6+/-5.3 mm Hg, with an IAP of 20 mm Hg or over in 2 of 17 patients, showing that they had already developed IAH. The IAP was significantly lower (P<0.05) 24 h after initiation of PMMA-CHDF, and subsequently decreased. There was a significant positive correlation between blood level of IL-6 and IAP, suggesting that PMMA-CHDF improved vascular permeability through elimination of cytokines, and that it thereby decreased interstitial edema to lower IAP. Sixteen of the 17 patients were discharged from the hospital in remission from SAP without development of complications. Continuous hemodiafiltration using a polymethyl methacrylate membrane hemofilter appears to be effective for prevention and treatment of IAH in patients with SAP through the removal of causative cytokines of hyperpermeability.     

Portal vein pulsatility index is a more important indicator than congestion index in the clinical evaluation of right heart function

AIM: To study the changes of portal blood flow in congestive heart failure. METHODS: We studied the congestion index (CI) and portal vein pulsatility index (PI) in patients with varied degrees of congestive heart failure using ultrasonic Doppler. Ten patients with (mean) right atrial pressure (RA) < 10 mmHg were classified as group 1 and the remaining 10 patients with RA > or = 10 mmHg as group 2. RESULTS: There were no difference on cardiac index (HI, P=0.28), aortic pressure (AO, P=0.78), left ventricular end-diastolic pressure (LVED, P=0.06), (max)imum portal blood velocity (Vmax, P=0.17), (mean) portal blood velocity (Vmean, P=0.15) and portal blood flow volume (PBF, P=0.95) between the two groups. Group 2 patients had higher pulmonary wedge pressure (PW, 29.9+/-9.3 mmHg vs 14.6+/-7.3 mmHg, P=0.002), pulmonary arterial pressure (PA, 46.3+/-13.2 mmHg vs 25.0+/-8.2 mmHg, P=0.004), RA (17.5+/-5.7 mmHg vs 4.7+/-2.4 mmHg, P<0.001), right ventricular end-diastolic pressure (RVED, 18.3+/-5.6 mmHg vs 6.4+/-2.7 mmHg, P<0.001), CI (8.7+/-2.4 vs 5.8+/-1.2, P=0.03), and PI (87.8+/-32.3% vs 27.0+/-7.4%, P<0.001) than Group 1. CI was correlated with PI (P<0.001), PW (P<0.001), PA (P<0.001), RA (P=0.043), RVED (P=0.005), HI (P<0.001), AO (P<0.001), CO (P<0.001), LVED (P<0.001), Vmax (P<0.001), Vmean (P<0.001), cross-sectional area of the main portal vein (P<0.001) and PBF (P<0.001). CI could be as high as 8.3 in patients with RA < 10 mmHg and as low as 5.9 in those with RA > or = 10 mmHg. CONCLUSION: Our data show that RI is a more significant indicator than CI in the clinical evaluation of high RA > or = 10 mmHg, whereas CI is better than PI in the assessment of left heart function.     

Electrocardiographic left ventricular hypertrophy in GUSTO IV ACS: an important risk marker of mortality in women.

AIM: To examine the association of left ventricular hypertrophy (LVH) on admission electrocardiography with adverse outcomes in acute coronary syndrome (ACS) patients. METHODS AND RESULTS: A total of 7443 non-ST-elevation ACS patients in Global Utilization of STrategies to Open occluded arteries (GUSTO) IV ACS trial had admission electrocardiograms analysed at a core laboratory. LVH [>or=20 mm Cornell voltage (LV voltage) (women) or >or=28 mm (men) plus strain patterns] was observed in 586 (7.9%) patients, and women accounted for 74%. LVH patients were also older and had more co-morbidities, ST-depression >or= 0.5 mm, elevated C-reactive protein and N-terminal pro-brain naturetic peptide (NT-proBNP), and lower troponin T. Invasive procedures occurred less often in LVH patients (cardiac catheterization: 31 vs. 38%, P = 0.001; percutaneous coronary intervention: 12 vs. 20%, P < 0.001). Mortality was significantly higher in patients with LVH (30 day: 5 vs. 3%, P = 0.046; 1 year: 14 vs. 7%, P < 0.001), whereas 30 day myocardial infarction (MI) and death/MI did not differ. After baseline adjustment including NT-proBNP, LVH remained associated with increased hazard of 1 year mortality in women, but not in men [P-interaction = 0.033; women: adjusted hazard ratio (LVH vs. no LVH): 1.42 (1.04-1.94), P = 0.029]. CONCLUSION: Electrocardiographic-LVH identifies an important subset of ACS patients with a higher risk of long-term mortality, particularly among women. These novel findings highlight opportunities to improve treatment and outcome among similar ACS patients.     

The Relationship Between Intestinal Hypoperfusion and Serum D-Lactate Levels During Experimental Intra-Abdominal Hypertension

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) may result from several clinic situations and carries high morbidity and mortality risk, particularly in intensive care unit patients. The clinical spectrum changes from splanchnic hypoperfusion and intestinal ischemia to multiple organ failure. Previous studies demonstrated that serum D-lactate levels may be an early indicator in intestinal ischemia. This study aimed to investigate the relationship between intestinal ischemia and serum D-lactate levels during experimental IAH. Thirty-two male Wistar Albino rats weighing 250+/-50 g were divided into four groups. Three different intra-abdominal pressure (IAP) levels supplied by placement of an intraperitoneal Peritofix catheter and iso-osmotic polyethylene glycol infusion. Each of the IAP levels (15, 20, and 25 mm Hg groups) was checked with the monitor system and fixed for an hour. Control-group animals were not subjected to increased IAP. One hour later, 5-ml blood samples were taken for measurement of serum D-lactate levels and 2-cm intestinal tissue samples were taken 5 cm proximal to the ileocecal valve for histopathologic examination. Elevated serum D-lactate levels were recorded in animals with higher IAP levels.There was a positive correlation between serum D-lactate levels and IAP levels. Histological examinations of the intestinal tissue samples showed no significant pathologic changes in concordance with intestinal ischemia. Serum D-lactate levels may be an early indicator for increased IAP pressure before intestinal ischemic changes occur.     

缺血修饰白蛋白对急性心肌缺血早期诊断价值的探讨

目的探讨缺血修饰白蛋白（IMA）测定对急性心肌缺血的早期诊断价值。方法采用白蛋白钴结合试验检测830例健康体检者（健康对照组）、492例急性冠状动脉综合征患者（ACS组）、74例单纯性高血压病患者（高血压组）、78例病毒性心肌炎患者（病毒性心肌炎组）、395例急性胸痛者（急性胸痛组,包括急诊ACS患者133例与随诊胸痛患者262例）和68例接受经皮冠状动脉介入治疗术患者（PCI组）血清或血浆IMA水平,并对其中急诊ACS患者进行IMA水平动态观察及血清肌钙蛋白I（cTnI）和心电图检测。结果根据ROC曲线,当临界值为0．45时综合评价最佳。ACS组和病毒性心肌炎组IMA水平分别为（0．55±0．11）吸光度单位（ABSU）和（0．38±0．11）ABSU,高于健康对照组[（0．34±0．08）ABSU,P〈0．05],且ACS组和病毒性心肌炎组之间IMA差异有统计学意义（P〈0．05）。急性胸痛组中急诊ACS患者IMA水平及阳性率分别为（0．54±0．12）ABSU和77．4％,高于随诊者的（0．44±0．12）ABSU和39．3％（P〈0．01）。在133例急诊ACS患者中,首诊1h内IMA阳性率为82．O％,高于同期cTnI阳性率40．6％（P〈0．01）,就诊后6—24hIMA与cTnI水平及阳性率较首诊1h内显著升高（P〈0．01）。在72例急性胸痛发作3h内入院且cTnI均为阴性的ACS患者中,首诊IMA阳性率为86．1％,心电图阳性率为72．2％,两者联合测定阳性率为93．1％。PCI术后即刻患者动脉血浆IMA水平较术前IMA明显升高（P〈0．05）。首诊ACS患者IMA水平高于临界值,于入院1天达峰值,且持续升高,后缓慢下降,入院14天IMA均值接近正常水平。结论IMA早期诊断急性心肌缺血具有临床应用价值。     

Acute and long-term effects of atrioventricular junction ablation and VVIR pacemaker in symptomatic patients with chronic lone atrial fibrillation and normal ventricular response

INTRODUCTION: The precise role of irregular ventricular response in atrial fibrillation (AF) has not been fully elucidated. This study examined the independent effects of rhythm regularity in patients with chronic AF. METHODS AND RESULTS: This study included 50 patients who had chronic lone AF and a normal ventricular rate. Among these patients, 21 who underwent AV junction ablation and implantation of a VVIR pacemaker constituted the ablation group; the other 29 patients were the medical group. Acute hemodynamic findings were measured in 21 ablation patients before ablation (during AF, baseline) and 15 minutes after ablation (during right ventricular pacing). Compared with baseline data, ablation and pacing therapy increased cardiac output (4.7 +/- 0.8 vs 5.2 +/- 0.9 L/min; P = 0.05), decreased pulmonary capillary wedge pressure (16 +/- 5 vs 13 +/- 4 mmHg; P = 0.001), and decreased left ventricular end-diastolic pressure (14 +/- 4 vs 11 +/- 3 mmHg; P < 0.05). After 12 months, the ablation group patients showed lower scores in general quality of life (-20%; P < 0.001), overall symptoms (-24%; P < 0.001), overall activity scale (-23%; P = 0.004), and significant increase of left ventricular ejection fraction (44% +/- 6% vs 49% +/- 5%; P = 0.02) by echocardiographic examination. CONCLUSION: AV junction ablation and pacing in patients with chronic AF and normal ventricular response may confer acute and long-term benefits beyond rate control by eliminating rhythm irregularity.     

Correlation between procalcitonin and intra-abdominal pressure and their role in prediction of the severity of acute pancreatitis

Background/aimsEarly assessment of disease severity and vigilant patient monitoring are key factors for adequate treatment of acute pancreatitis (AP). The aim of this study was to determine the correlation of procalcitonin (PCT) serum concentrations and intra-abdominal pressure (IAP) as prognostic markers in early stages of AP.MethodsThis prospective observational study included 51 patients, of which 29 had severe AP (SAP). Patients were evaluated with the Acute Physiology And Chronic Health Evaluation (APACHE II) score, C-reactive protein (CRP) and PCT serum concentrations and IAP at 24 h from admission. PCT was measured three times in the 1st week of disease and three times afterward, while IAP was measured daily. PCT and IAP values correlated with each other, and also compared with APACHE II score and CRP values.ResultsPCT, IAP, CRP values and APACHE II score at 24 h after hospital admission were significantly elevated in patients with SAP. There was significant correlation between PCT and IAP values measured at 24 h of admission, and between maximal PCT and IAP values. Sensitivity/specificity for predicting AP severity at 24 h after admission was 89%/69% for APACHE II score, 75%/86% for CRP, 86%/63% for PCT and 75%/77% for IAP.ConclusionsIncreased IAP was accompanied by increased PCT serum concentration in patients with AP. PCT and IAP can both be used as early markers of AP severity.     

Predictors for development of multiple organ dysfunction syndrome in elderly patients with acute myocardial infarction

Multiple organ dysfunction syndrome (MODS) is one of the leading causes of death in ICU patients.However,there have been few studies on the role of MODS as a cause of death in patients with acute myocardial infarction (AMI),particularly in those at advanced age.Our study aimed to investigate the incidence and to identify the predicting factors of MODS in elderly patients with AMI.Methods We identified consecutive patients with AMI who were discharged from the Chinese PLA General Hospital between January 1993 to June 2006.Medical records of 800 consecutive patients aged 60 years or over were analyzed retrospectively.Multivariate logistic regression was used to determine factors predicting in-hospital development of MODS.Results Twenty-seven (3.4%) patients developed MODS within 30 days after AMI.Compared with patients without MODS,patients with MODS had higher in-hospital mortality rates (55.6% vs 11.6%,P＜0.001 ) and more frequent complications of cardiogenic shock (25.9% vs 6.2%,P＜0.001),heart failure (HF) (59.3% vs 18.2%,P＜0.001 ),cardiac arrhythmia (44.4% vs 26.4%,P＜0.05) and pneumonia (55.6% vs 16.3%,P＜0.001).Multivariate logistic regression analysis showed the major predictors for the occurrence of MODS secondary to AMI were advanced age (≥ 75 years,odds ratio 2.64,95% confidence interval [CI] 1.13 to 6.61),heart rate/＞ 100 bpm on admission (odds ratio 1.74,[CI] 1.14 to 2.64),in-hospital complication of HF (odds ratio 3.03,[CI] 1.26 to 7.26) and pneumonia (odds ratio 2.82,[CI] 1.18 to 6.77).Conclusions MODS is not the uncommon complication in elderly patients with AMI and is associated with poor prognosis.Advanced age,heart failure and pneumonia are predictors of the development of MODS in patients with AMI.(J Geriatr Cardiol 2008;5:199-202)     

急性冠状动脉综合征合并肾功能不全的支架术治疗

目的　评估急性冠状动脉 (冠脉 )综合征合并肾功能不全患者经皮腔内支架术的预后。方法　 6 3例急性冠脉综合征合并肾功能不全行冠脉内和或肾动脉支架植入术患者 (肾功能不全组 ) ,随机选取同期 6 3例一般情况匹配 ,肾功能正常行介入治疗患者 (对照组 )。比较两组临床特征、血管造影、支架术及随访情况。结果　肾功能不全组患者血清肌酐水平显著增高 [(177± 31) μmol/L比(98± 2 1) μmol/L ,P <0 0 0 1]、左室射血分数减低 (0 4 5± 0 10比 0 5 0± 0 0 9,P <0 0 5 ) ,冠脉多支病变增多 (84 %比 6 5 % ,P <0 0 5 )且肾动脉狭窄发生率显著增高 (2 7%和 8% ,P <0 0 5 ) ,13例患者在冠脉支架术同时行肾动脉支架术 (比较对照组 2例 ,P <0 0 5 ) ;两组冠脉支架术手术成功率和术中并发症相似 ;随访表明 ,肾功能不全组严重心脏不良事件发生率较高 (13%和 8% ,P =0 38) ,平均血清肌酐水平较术前降低 (177± 31μmol/L和 14 7± 11μmol/L ,P <0 0 5 ) ,9例 (6 9% )肾动脉狭窄患者肾动脉支架术后血清肌酐恢复正常。结论　急性冠脉综合征合并肾功能不全患者冠脉支架术安全、有效 ,2 / 3接受肾动脉支架术患者术后血清肌酐恢复正常。     

早期阿托伐他汀联合普罗布考治疗对急性冠状动脉综合征患者血管内皮功能的影响

目的 观察阿托伐他汀联合普罗布考早期治疗对急性冠状动脉综合征(ACS)患者血管内皮功能的影响.方法 30例ACS患者在入院24 h内随机分到他汀组(阿托伐他汀20 mg/d,n=15)与联合治疗组(阿托伐他汀20 mg/d和普罗布考500 mg/d,n=15).治疗前、治疗1周和4周后分别检测患者血清血脂与高敏C反应蛋白(hs-CRP)水平,并应用高频超声测肱动脉血流介导的内皮依赖血管舒张功能(FMD)和由硝酸甘油诱导的内皮非依赖血管舒张功能(NMD).结果 经治疗1和4周后,两组血清总胆固醇、低密度脂蛋白胆固醇(LDL-C)和hs-CRP水平均低于治疗前,联合治疗组血清总胆蚓醇水平下降较他汀组更明显(P<0.05).治疗1周后,FMD均明显高于治疗前(他汀组:3.75%±0.78%比1.09%±0.44%;联合治疗组:3.67%±0.36%比1.24%±0.37%;均P<0.01),两组比较差异无统计学意义.联合治疗组4周后FMD明显高于1周后(6.85%±0.64%比3.67%±0.36%,P<0.01);他汀组则无显著变化(P=0.954).两组NMD在治疗4周后均明显高于治疗前(P<0.01),但两组比较差异无统计学意义.相关分析显示,FMD和NMD的改善与血脂或hs-CRP水平的变化无显著相关.结论 提示早期阿托伐他汀联合普罗布考治疗较单用阿托伐他汀能更明显地改善ACS患者的血管内皮功能.     

Haemodynamic response to abdominal decompression in acute Budd–Chiari syndrome

Background: Intra‐abdominal hypertension (IAH) and abdominal compartment syndrome commonly occur in patients with liver disease. Aims: We compared haemodynamic variables pre‐ and post‐abdominal decompression in patients with acute Budd–Chiari syndrome (BCS) and patients with chronic liver disease (CLD), ascites and IAH. Methods: Patients with IAH admitted to the Liver ICU, King's College Hospital were studied. Transpulmonary thermodilution cardiac output (CO) monitoring was performed with the PiCCO^® system. Results: Ten patients with decompensated BCS (median age 39 years, 20–52) and eight patients with CLD (59 years, 33–65) and tense ascites requiring paracentesis were studied. Intra‐abdominal pressure (IAP) was raised in both groups pre‐intervention (BSC 23 mmHg, 17–40; CLD 26, 20–40). Intrathoracic blood volume (ITBVI) was persistently low in the BCS group (632 ml/m², 453–924) despite volume resuscitation. Post‐intervention, reduction in IAP was noted in both groups (BCS P<0.001, CLD P<0.0001). The ITBVI increased (P=0.001) in the BCS group only. An increase in cardiac index (CI) and stroke volume index (SVI) was noted in both groups (BCS: CI P=0.003, SVI: P=0.007; CLD: CI P=0.005, SVI P=0.02). The central venous pressure did not change in either group and did not correlate with markers of flow (CI, SVI) or IAP. Both groups demonstrated an inverse relationship between IAP, CI and SVI. Conclusion: Patients with BCS and IAH have evidence of central hypovolaemia. In addition to raised IAP, hepatic venous obstruction and caudate lobe hypertrophy limit venous return in patients with BCS. Reduction in IAP and re‐establishment of caval flow restores preload with improvement in CO.     

Low rates of exercise in patients with metabolic syndrome after an acute coronary syndrome

BACKGROUND: Metabolic syndrome (MetSyn) has reached epidemic proportions; however, regular exercise can prevent its progression to type 2 diabetes. HYPOTHESIS: The study was undertaken to determine both the rate and predictors of routine exercise 1 year after an acute coronary syndrome (ACS) in patients with MetSyn. METHODS: In a registry of 1,199 patients presenting with ACS, those with MetSyn were identified using the modified NCEP-ATP III criteria. Baseline and 1-year exercise patterns were examined in these patients, and the characteristics of those who were exercising were then compared with those who were not. A multivariable logistic regression analysis was subsequently conducted to identify independent predictors of exercise at 1 year. RESULTS: Of 273 patients with MetSyn, baseline and 1-year data about patients' exercise patterns were available for 170, of whom only 92 (54.2%) were exercising at 1 year. Characteristics that differed between those who were and those who were not exercising at 1 year included exercise at baseline (40 vs. 16.7%, p<0.001), Caucasian race (92.4 vs. 79.5%, p = 0.01), and body mass index (BMI) (30.4 +/- 4.3 vs. 32.1 +/- 5.0, p = 0.02). In a multivariable analysis, significant independent predictors of exercise were routine exercise at the time of admission for ACS (odds ratio [OR] = 2.6,95% confidence interval [CI] = 1.1-6.4), younger age (OR = 0.67 per 10-year increase [95% CI = 0.45-0.99]), and lower BMI (OR = 0.4 per 10-unit increase [95% CI = 0.17-0.911). CONCLUSIONS: Almost half of patients with MetSyn did not participate in routine exercise 1 year after their admission for ACS. Innovative strategies are needed to increase exercise participation in such patients, particularly those not exercising at baseline as well as obese and older patients.     

Effects of GH replacement on 24-h ambulatory blood pressure and its circadian rhythm in adult GH deficiency

OBJECTIVE: Increased prevalence of hypertension and cardiovascular mortality have been reported in hypopituitary patients who had been appropriately replaced with conventional pituitary hormones except GH. Growth hormone replacement (GHR) results in improvement of surrogate markers of cardiovascular function. Data on effects of GHR on blood pressure (BP) in adult growth hormone deficiency (AGHD), however, remain contradictory. There are as yet no reports on BP circadian rhythms in untreated or treated AGHD. Therefore, in a 12-month follow-up study, we evaluated the effects of GHR on ambulatory blood pressure (ABP) in AGHD patients. STUDY DESIGN: A prospective, open treatment design study to determine the effects of GHR on ABP and heart rate in AGHD patients. GH was commenced at a daily dose of 0.5 IU, and titrated up by increments of 0.25 IU at 4-weekly intervals to achieve and maintain IGF-I standard deviation score (IGF-I SD) between the median and upper end of the age-related reference range. PATIENTS: Twenty-two, post-pituitary surgery, severe AGHD patients (11 men), defined as peak GH response < 9 mU/l to provocative testing were recruited. The mean age +/- SEM was 48.8 +/- 2.5 years. Twenty-one patients required additional pituitary replacement hormones following pituitary surgery and were on optimal doses at recruitment. MEASUREMENTS: Twenty-four-hour ABP and heart rate (HR), body mass index (BMI), waist hip ratio (WHR) and total body water (TBW) were measured before and after 12 months on GHR. Cosinor analysis was used to analyse BP and HR circadian rhythm parameter estimates. RESULTS: Target IGF-I SD was achieved within 3 months of commencement of GHR in all patients (-3.5 +/- 0.4 at baseline vs. 0.8 +/- 0.2 at 3 months, P < 0.001) and remained within range at 12 months (1.1 +/- 0.2, P < 0.001 compared to baseline). A significant increase in TBW (45.8 +/- 1.2 vs. 47.8 +/- 1.5 kg, P < 0.05) but no significant change in BMI (30.7 +/- 2.2 vs. 31.8 +/- 2.7, P = NS) or WHR (0.95 +/- 0.02 vs. 0.93 +/- 0.02, P = NS) was observed after 12 months on GHR. The 24-h mean systolic ABP (SBP; 126.2 +/- 2.8 vs. 120.1 +/- 2.7 mmHg, P < 0.001) and diastolic ABP (DBP; 78.2 +/- 1.6 vs. 71.4 +/- 1.8 mmHg, P < 0.001) significantly decreased following GHR with a parallel increase in 24-h mean HR (69.6 +/- 2.5 vs. 73.8 +/- 2.5 beats/min; P < 0.001). A significant nocturnal decrease in SBP and DBP was observed both before (SBP; daytime, 129.1 +/- 2.8 vs. night time, 115.9 +/- 3.0 mmHg, P < 0.001 and DBP; daytime, 80.7 +/- 1.6 vs. night time, 69.2 +/- 1.8 mmHg, P < 0.001) and following GHR (SBP; daytime, 122.8 +/- 2.6 vs. night time, 110.0 +/- 3.6 mmHg, P < 0.001 and DBP; daytime, 73.9 +/- 1.8 vs. night time, 62.0 +/- 2.3 mmHg, P < 0.001). Individual and population-mean cosinor analysis demonstrated significant circadian rhythms for SBP, DBP and HR before and after 12 months on GHR (P < 0.001), suggesting that SBP, DBP and HR circadian rhythms were not altered by GHR. There was, however, a significant reduction in SBP (124.2 +/- 2.8 vs. 118.4 +/- 2.8 mmHg, P < 0.001) and DBP (77.0 +/- 1.6 vs. 70.2 +/- 1.8 mmHg, P < 0.001) MESOR with an increase in HR MESOR (68.9 +/- 2.5 vs. 72.2 +/- 2.4 beats/min, P < 0.01) following GHR. CONCLUSIONS: Systolic and diastolic BP and HR circadian rhythms are preserved in AGHD following 12 months of GHR. However, there is a significant decrease in 24-h mean SBP and DBP and increase in 24-h mean HR after 12 months on GHR. We postulate that this decrease in 24-h mean SBP and DBP may result in a reduction of cardiovascular morbidity and mortality and may explain the beneficial effects of GHR on cardiovascular system previously reported in AGHD patients.     

Regional variations in racial differences in the treatment of elderly patients hospitalized with acute myocardial infarction

PURPOSE: Racial differences in the treatment of patients with myocardial infarction are often presented as nationally consistent patterns of care, despite known regional variations in quality of care. We sought to determine whether racial differences in myocardial infarction treatment vary by U.S. census region. METHODS: We conducted a retrospective analysis of medical record data from 138,938 elderly fee-for-service Medicare beneficiaries hospitalized with myocardial infarction between 1994 and 1996. Patients were evaluated for the use (admission, discharge) of aspirin and beta-blockers, and cardiac procedures (cardiac catheterization, any coronary revascularization) within 60 days of admission. RESULTS: Nationally, black patients had lower crude rates of aspirin and beta-blocker use, cardiac catheterization, and coronary revascularization than did white patients. Racial differences in treatment, however, varied by region. Black patients in the Northeast had rates of aspirin use that were similar to those of white patients on admission (50.6% vs. 49.8%, P = 0.58) and at discharge (77.5% vs. 74.2%, P = 0.07), whereas racial differences were observed in the South (admission: 43.7% vs. 48.8%, P <0.001; discharge: 69.5% vs. 73.2%, P <0.001), Midwest (admission: 48.4% vs. 52.3%, P = 0.004), and West (admission: 49.2% vs. 56.2%, P <0.001; discharge: 70.7% vs. 76.2%, P = 0.02). Racial differences in beta-blocker use were comparable across regions (admission: P = 0.59, discharge: P = 0.89). There were no differences in cardiac catheterization use among black and white patients in the Northeast (38.9% vs. 40.5%, P = 0.24), as opposed to the Midwest (43.3% vs. 48.9%, P <0.001), South (39.2% vs. 48.5%, P <0.001), and West (38.3% vs. 48.6%, P <0.001). Similarly, racial differences in any coronary revascularization use were smallest in the Northeast (22.1% vs. 26.7%, P <0.001), greater in the Midwest (24.7% vs. 33.5%, P <0.001), and largest in the South (20.7% vs. 32.0%, P <0.001) and West (22.9% vs. 33.7%, P <0.001). Regional variations in racial differences persisted after multivariable adjustment for aspirin on admission (P = 0.09) and any coronary revascularization (P = 0.10). CONCLUSION: Racial differences in the use of some therapies for myocardial infarction in patients hospitalized between 1994 and 1996 varied by region, suggesting that national evaluations of racial differences in health care use may obscure potentially important regional variations.