Doppler Tissue Imaging: A Noninvasive Technique for Evaluation of Left Ventricular Relaxation and Estimation of Filling Pressures

BACKGROUND Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatment of shock. There is a continuing controversy about whether one agent is superior to the other. METHODS In this multicenter, randomized trial, we assigned patients with shock to receive either dopamine or norepinephrine as first-line vasopressor therapy to restore and maintain blood pressure. When blood pressure could not be maintained with a dose of 20 μg per kilogram of body weight per minute for dopamine or a dose of 0.19 μg per kilogram per minute for norepinephrine, open-label norepinephrine, epinephrine, or vasopressin could be added. The primary outcome was the rate of death at 28 days after randomization; secondary end points included the number of days without need for organ support and the occurrence of adverse events. RESULTS The trial included 1679 patients, of whom 858 were assigned to dopamine and 821 to norepinephrine. The baseline characteristics of the groups were similar. There was no significant between-group difference in the rate of death at 28 days (52.5% in the dopamine group and 48.5% in the norepinephrine group; odds ratio with dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P = 0.10). However, there were more arrhythmic events among the patients treated with dopamine than among those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P<0.001). A subgroup analysis showed that dopamine, as compared with norepinephrine, was associated with an increased rate of death at 28 days among the 280 patients with cardiogenic shock but not among the 1044 patients with septic shock or the 263 with hypovolemic shock (P = 0.03 for cardiogenic shock, P = 0.19 for septic shock, and P = 0.84 for hypovolemic shock, in Kaplan–Meier analyses). CONCLUSIONS Although there was no significant difference in the rate of death between patients with shock who were treated with dopamine as the first-line vasopressor agent and those who were treated with norepinephrine, the use of dopamine was associated with a greater number of adverse events. (ClinicalTrials.gov number, NCT00314704.)

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Comparison of Dopamine and Norepinephrine in the Treatment of Shock

Guidelines and Expert Consensus documents aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making.

A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and by different organizations and other related societies. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents.

In spite of the fact that standards for issuing good quality Guidelines and Expert Consensus Documents are well defined, recent surveys of Guidelines and Expert Consensus Documents published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilization of health resources.

The ESC Committee for Practice Guidelines (CPG) supervises and coordinates the preparation of new Guidelines and Expert Consensus Documents produced by Task Forces, expert groups or consensus panels. The chosen experts in these writing panels are asked to provide disclosure statements of all relationships they may have which might be perceived as real or potential conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. The Committee is also responsible for the …

https://repositorio.chporto.pt/bitstream/10400.16/493/1/pdf.4.pdf

Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology.

Table of contents Preamble Scope of the document 1256 Method 1257 Part 1. Classification, epidemiology and prognosis Definition 1258 Brief overview of pathophysiology of syncope 1258 Classification 1259 Epidemiological considerations 1259 Prognostic stratification: identification of factors predictive of adverse outcome 1260 Part 2. Diagnosis Strategy of evaluation (flow chart) 1262 Initial evaluation (history, physical examination, baseline electrocardiogram) 1264 Echocardiogram 1266 Carotid sinus massage 1266 Tilt testing 1268 Electrocardiographic monitoring (non-invasive and invasive) 1271 Electrophysiological testing 1273 ATP test 1277 Ventricular signal-averaged electrocardiogram 1278 Exercise testing 1278 Cardiac catheterization and angiography 1279 Neurological and psychiatric evaluation 1279 Diagnostic yield and prevalence of causes of syncope 1282

Guidelines on management (diagnosis and treatment) of syncope

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously.

A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines/rules).

In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed including the assessment of the risk/benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tables 1 and  2 .

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 Table 1 
Classes of recommendations



View this table:

 Table 2 
Levels of evidence



The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified …

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Guidelines for cardiac pacing and cardiac resynchronization therapy: The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in collaboration with the European Heart Rhythm Association.

Cardiac conduction was investigated at the time of pacemaker insertion in 15 patients with symptomatic sinus node disease. Techniques included recording of His bundle potentials, atrial pacing at various heart rates, and atropine administration. Atrioventricular (AV) conduction was impaired in eight patients who manifested one or more of the following: P-R prolongation, P-H prolongation, and development of second degree AV block with atrial pacing at heart rates below 130 beats/min. Five patients had intraventricular conduction defects diagnosed electrocardiographically; none of these had H-Q prolongation. One of these five, with left bundle-branch block, subsequently developed complete heart block and had a calcific lesion involving the His bundle. Depression of cardiac automaticity was noted in four patients, with asystolic periods greater than 2 sec after sudden cessation of atrial pacing at rates of 100-160 beats/min. Responses to 1 mg of intravenous atropine were varied, but no patient developed sinus rates greater than 90 beats/min, suggesting the presence of primary sinus node dysfunction.

In conclusion, abnormalities of conduction and automaticity in specialized tissue in addition to the sinus node are common in patients with symptomatic sinus node disease. These abnormalities should be recognized when present, so that the ideal site for permanent pacing may be chosen.

Cardiac conduction in patients with symptomatic sinus node disease.

The hemodynamic effects of dopamine were studied in 62 patients with clinical shock. In 36 patients with infection dopamine increased mean arterial pressure (MAP) 30%, and cardiac output (CO) 37%. Urine flow (UF) increased from 0.5 ml/min to 1.6 ml/min. Norepinephrine (NE) in 26 patients resulted in a higher MAP, lower CO, and similar UF. Isoproterenol (Isp) in 19 patients resulted in a lower MAP, higher CO, and a significantly lower UF. In 13 patients with cardiogenic shock dopamine increased MAP 6%, and CO 40%. UF increased from 0.6 ml/min to 1.1 ml/min. NE in eight patients resulted in a lower CO than during dopamine infusion, and Isp in five patients resulted in a higher CO. Dopamine improves MAP pressure, CO, and UF when shock is due to infection and is superior to Isp which does not increase perfusion pressure to adequate levels and does not improve UF. In patients with cardiogenic shock who have reduced CO and increased systemic vascular resistance, perfusion pressure tended to be adequate, and imp...

Acute Hemodynamic Effects of Dopamine in Patients with Shock

His and right bundle electrograms were recorded in a patient with unexplained P-R prolongations and periods suggestive of both type I and II second degree A-V block. The mechanism of these conduction disturbances was shown to be due to multiple nonpropagated premature His bundle depolarizations (H') which produced their effects on the subsequent cycle by virtue of concealed conduction into the A-V junction. The effects on A-V conduction were related to the time of occurrence of H' in relation to the subsequent P wave: If H'-P was short, a more profound conduction defect occurred. H' was generally undetectable on the ECG because of both antegrade and retrograde block, but a few propagated H' produced typical junctional premature contractions. Propagation of H' depended on a short preceding cycle length and a late occurrence of H'. The site of origin of H' appeared to be in the bundle of His. The mechanism of production of H' did not appear to be either reentry or parasystole. The term pseudo A-V block is u...

Pseudo A-V Block Secondary to Premature Nonpropagated His Bundle Depolarizations Documentation by His Bundle Electrocardiography

Bundle of His electrograms were recorded in eight patients with acute myocardial infarction and heart block. Three patients with diaphragmatic myocardial infarction (DMI) and one with subendocardial infarction were characterized by slowing or block above the bundle of His and A-V junctional escape rhythms during periods of advanced or complete block. An additional patient with DMI had block in the His bundle itself. Intraventricular conduction in the above patients was characterized by normal H-Q intervals (35 to 60 msec) and absence of widened QRS. In contrast, three patients with anterior infarction (AMI) manifested complete block below the bundle of His and idioventricular escape. P-H intervals were normal (80 to 140 msec) and A-V conduction was considered unaffected. Our electrophysiologic observations coupled with previous clinical, anatomic, and pathologic findings suggest that the heart block in DMI is usually due to an ischemic lesion of the A-V node, while heart block in AMI is due to necrosis in...

Site of Heart Block in Acute Myocardial Infarction

We have measured pulmonary artery (PA) and left ventricular diastolic pressures (LVDP) in patients with acute myocardial infarction to establish the relationships of PA pressure to LVDP. Paired determinations for the various parameters showed (mean difference in mm Hg): left ventricular end-diastolic pressure (LVEDP)-LVDP pre-a + 7.9, P 0.2; PA end-diastolic pressure (PAEDP)-mean PA wedge (in all patients) +3.3, P < 0.001; PAEDP-mean PA wedge (patients with pulmonary vascular resistance ≦2 units) +1.3, P < 0.1; LVEDP-PAEDP +4.7, P < 0.001; and LVEDP-mean PA –2.0, P < 0.02. The relationship of LVEDP to mean PA wedge was: LVEDP (y) = 1.12 mean PA wedge (x) +4.69; Sy.x = 3.42; r = 0.92. After acute myocardial infarction, PA pressures did not accurately reflect LVEDP because atrial contraction made a large contribution to ventricular filling pressure. In addition, PAEDPs were not the same as mean PA wedge pressures because of ...

Shahbudin H. Rahimtoola

Papers

Cardiac conduction in patients with symptomatic sinus node disease.

Acute Hemodynamic Effects of Dopamine in Patients with Shock

Pseudo A-V Block Secondary to Premature Nonpropagated His Bundle Depolarizations Documentation by His Bundle Electrocardiography

Site of Heart Block in Acute Myocardial Infarction

Relationship of Pulmonary Artery to Left Ventricular Diastolic Pressures in Acute Myocardial Infarction