Components of heart rate variability have attracted considerable attention in psychology and medicine and have become important dependent measures in psychophysiology and behavioral medicine. Quantification and interpretation of heart rate variability, however, remain complex issues and are fraught with pitfalls. The present report (a) examines the physiological origins and mechanisms of heart rate variability, (b) considers quantitative approaches to measurement, and (c) highlights important caveats in the interpretation of heart rate variability. Summary guidelines for research in this area are outlined, and suggestions and prospects for future developments are considered.

https://www.onlinelibrary.wiley.com/doi/epdf/10.1111/j.1469-8986.1997.tb02140.x

Heart rate variability: Origins, methods, and interpretive caveats

2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC).

结节病易误诊,据王洪武等~([1])收集国内18篇关于此病误诊的文献,误诊率高达63.2%,当然有误诊就会有误治,如孙永昌等~([2])报道26例结节病在影像学检查诊断的第一印象中拟诊结核5例,其中就有2例完成规范的抗结核治疗,为此应引起临床对本病诊治的重视。

Sarcoidosis

Acute myocardial infarction (MI) is a major cause of death and disability worldwide. In patients with MI, the treatment of choice for reducing acute myocardial ischemic injury and limiting MI size is timely and effective myocardial reperfusion using either thombolytic therapy or primary percutaneous coronary intervention (PPCI). However, the process of reperfusion can itself induce cardiomyocyte death, known as myocardial reperfusion injury, for which there is still no effective therapy. A number of new therapeutic strategies currently under investigation for preventing myocardial reperfusion injury have the potential to improve clinical outcomes in patients with acute MI treated with PPCI.

https://dm5migu4zj3pb.cloudfront.net/manuscripts/62000/62874/JCI62874.v1.pdf

Myocardial ischemia-reperfusion injury: a neglected therapeutic target

The recommendations in this 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) after the publication of the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 1,2 and was completed in February 2015.3,4

In this in-depth evidence review process, ILCOR examined topics and then generated a prioritized list of questions for systematic review. Questions were first formulated in PICO (population, intervention, comparator, outcome) format,5 and then search strategies and inclusion and exclusion criteria were defined and a search for relevant articles was performed. The evidence was evaluated by the ILCOR task forces by using the standardized methodological approach proposed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group.6

The quality of the evidence was categorized based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias). Then, where possible, consensus-based treatment recommendations were created.

To create this 2015 Guidelines Update, the AHA formed 15 writing groups, with careful attention to manage conflicts of interest, to assess the ILCOR treatment recommendations and to write AHA treatment recommendations by using the AHA Class of Recommendation (COR) and Level of Evidence (LOE) system. The recommendations made in the Guidelines are informed by the ILCOR recommendations and GRADE classification, in the context of the delivery of medical care in North America. The AHA writing group made new recommendations only on topics specifically reviewed by ILCOR in 2015. This chapter delineates instances where the AHA writing group developed recommendations that are significantly stronger or weaker than the ILCOR statements. In the online …

Part 8: Post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care

BACKGROUND Anemia is common in patients with sepsis but its mechanism is unknown. We tested the hypothesis that effects on erythropoiesis evoked by darbepoetin alfa (DA), a long-acting erythropoietin analog, are diminished by lipopolysaccharide (LPS). METHODS We performed a prospective, controlled, randomized animal study (male Lewis rats n = 44). The interventions we used were intraperitoneal injection of Escherichia coli LPS (10 mg/kg) or vehicle followed by either DA (25 microg/kg) or vehicle (four experimental groups). Blood and reticulocyte counts and variables of iron metabolism were measured at baseline and 3 and 14 days after interventions. RESULTS Animals treated with DA alone showed an eightfold increase in reticulocyte count from baseline on Day 3, whereas no increase was seen in animals administered LPS or LPS/DA. On Day 14, the red blood cell count and hemoglobin concentration had increased by approximately 10% from baseline (P < 0.001) in the DA group but had decreased after LPS on Days 3 and 14 (P < 0.05) and in animals administered LPS/DA. Consumption of iron was seen on Day 3 in the DA group but not after LPS or LPS/DA combined. Values of ferritin and transferrin did not change between groups. CONCLUSION LPS abolishes erythropoiesis and iron use evoked by DA and this is accompanied by a decrease in hemoglobin concentration and red blood cell concentration. Accordingly, endotoxin suppresses DAs ability to increase erythropoiesis.

Lipopolysaccharide evokes resistance to erythropoiesis induced by the long-acting erythropoietin analogue darbepoetin alfa in rats.

Characterization of the PLCB1 promoter and regulation by early growth response transcription factor EGR-1.

Pacemaker interactions with transcutaneous cardiac pacing.

Massive tissue necrosis and septic shock have recently been reported in a series of injection drug users in Scotland, England and Ireland. We report the first case outside the UK meeting the criteria for this new entity (septic shock without fever in an injection drug user, local and systemic inflammation, rhabdomyolysis and tissue necrosis at the injection site). Following surgical treatment and antibiotic treatment, the patient was cured and is currently well.

31-year-old injection drug user with massive skin necrosis and shock.

Remote ischaemic preconditiong (RIPC), at least in the context of cardioprotection during heart surgery, has arrived at an apparent deadlock. Following numerous laboratory investigations demonstrating smaller areas of myocardial infarction following RIPC (for review, see [6]), proof of principle studies revealing lesser postoperative cardiac troponin concentrations as well as smaller clinical studies both with positive or negative results [3, 11–13], a larger monocentric trial had demonstrated not only significantly decreased postoperative cardiac troponin concentrations but also a significant reduction of all-cause mortality and MACCE rates as secondary end points with intermediate time follow-up [23]. This indicated less myocardial damage following RIPC with repetitive left upper arm ischemia/reperfusion following coronary artery bypass graft (CABG) surgery under isoflurane anaesthesia. Recently, however, two large multicenter studies, the RIPHeart and ERRICA trials, failed to show any positive effects on troponin concentrations and clinical end points, including mortality [4, 16]. This resembles the situation with ischaemic preconditioning by intermittent coronary artery occlusion which never became a clinical routine [7], and leaves behind in reasonable frustration and disappointment both RIPC investigators and their clinician audience. Accordingly, it is clear now that RIPC is not an all purpose, easily implemented magic drink protecting all cardiac surgical patients and ensuring their longevity like a sip from the Holy Grail. In fact, the area under the curve of postoperative troponin concentrations, while likely reflecting cardiomyocyte injury during aortic crossclamping and subsequent reperfusion, is unlikely to strictly mirror clinical benefits for a patient and the mechanisms reflecting regional cardiac ischaemia/reperfusion in the awake state, such as during coronary stent interventions. However, it is premature to drop the final curtain in the RIPC theater. Rather, do not stop the music for a variety of reasons. First, let us not forget that the ultimate goal of RIPC research is not so much the efficacy of organ protection by simply blowing up blood pressure cuffs, perhaps giving physicians a less technical face and a long missed touch to treat by more natural means. Rather, we are only ready for prime time when the unique molecular downstream mechanism(s) of RIPC and their pathways have been solidly identified. Only then will we be able to mimic RIPC pharmacologically and with greater efficacy, likely yielding broad clinical applications. While RIPC mechanisms have not yet been identified in detail and there is evidence for a variety of humoral and neural pathways [1, 6–8, 19], scientific troops are bulleyeing this target closer and closer, effectively encircling potential mechanisms down to the mitochondria. Accordingly, there still is hope for a magic pill or injection, e.g., mitochondrial potassium channel agonists, so stay tuned and listen to the music. Second, there is reason to look critically at the recent clinical trials and their potential confounders. To this end, it now appears obvious and is widely discussed [8, 11, 12, 14, 24] that anaesthetics may have played a major role in RIPC trial results that address cardiac surgical patients. Currently, RIPC and anaesthetic action in cardiac surgery resembles a (yet) unhappy marriage unable to be divorced. & Jürgen Peters juergen.peters@uni-duisburg-essen.de

/pdf/anaesthetics-and-remote-ischaemic-preconditioning-do-not-3pt15b2sir.pdf

Jürgen Peters

Papers

Lipopolysaccharide evokes resistance to erythropoiesis induced by the long-acting erythropoietin analogue darbepoetin alfa in rats.

Characterization of the PLCB1 promoter and regulation by early growth response transcription factor EGR-1.

Pacemaker interactions with transcutaneous cardiac pacing.

31-year-old injection drug user with massive skin necrosis and shock.

Anaesthetics and remote ischaemic preconditioning: do not stop the music, despite a (yet) unhappy marriage