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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Targeting elevated left ventricular end-diastolic pressure following primary percutaneous coronary intervention for
Arshad A Khan1,2,3, Allan J Davies1, Nicholas J Whitehead1
1John Hunter Hospital, Newcastle, Australia.
Insights
This study found that combining glyceryl trinitrate and furosemide effectively lowers elevated left ventricular end-diastolic pressure (LVEDP) in ST-segment elevation myocardial infarction (STEMI) patients after percutaneous coronary intervention. This intervention safely reduces LVEDP without significant adverse effects.
Area of Science:
- Cardiology
- Critical Care Medicine
- Pharmacology
Background:
- Elevated left ventricular end-diastolic pressure (LVEDP) is a significant predictor of mortality and heart failure in ST-segment elevation myocardial infarction (STEMI) patients.
- The clinical benefit of actively lowering elevated LVEDP in STEMI patients remains uncertain.
Purpose of the Study:
- To investigate the efficacy and safety of a combination therapy with glyceryl trinitrate and furosemide in reducing elevated LVEDP.
- To assess the impact of this intervention on STEMI patients undergoing primary percutaneous coronary intervention.
Main Methods:
- A non-randomized, single-blinded study enrolled 20 STEMI patients with LVEDP ≥ 20 mmHg post-primary percutaneous coronary intervention.
- The intervention group (n=10) received intravenous furosemide and escalating doses of glyceryl trinitrate, while the control group (n=10) received saline.
- LVEDP was monitored simultaneously during treatment administration.
Main Results:
- The combination therapy group showed a significant reduction in LVEDP from 28±3 mmHg to 16±2 mmHg (p < 0.01).
- The control group experienced no significant change in LVEDP.
- A median dose of 200 µg glyceryl trinitrate was required to achieve a ≥ 20% LVEDP reduction, with one instance of asymptomatic hypotension.
Conclusions:
- Intravenous glyceryl trinitrate plus furosemide safely and effectively reduces elevated LVEDP in STEMI patients post-primary percutaneous coronary intervention.
- This therapeutic approach offers a potential strategy for managing elevated LVEDP in this patient population.
Introduction:
Elevated left ventricular end diastolic pressure (LVEDP) is an independent predictor of mortality and heart failure in patients with ST-segment elevation myocardial infarction (STEMI). Whether lowering elevated LVEDP improves outcomes remains unknown.
Methods:
This non-randomized, single blinded study with prospective enrolment and sequential group allocation recruited patients undergoing primary percutaneous coronary intervention for STEMI with LVEDP ⩾ 20 mmHg measured immediately after primary percutaneous coronary intervention. The intervention arm (n=10) received furosemide 40 mg intravenous bolus plus escalating doses of glyceryl trinitrate (100 µg per min to a maximum of 1000 µg) during simultaneous measurement of LVEDP. The control group (n=10) received corresponding normal saline boluses with simultaneous measurement of LVEDP (10 readings over 10 min). Efficacy endpoints were final LVEDP achieved, and the dose of glyceryl trinitrate needed to reduce LVEDP by ⩾ 20%. Safety endpoint was symptomatic hypotension (systolic blood pressure < 90 mmHg).
Results:
From 1 April 2017 to 23 August 2017 we enrolled 20 patients (age: 64±9 years, males: 60%, n=12, anterior STEMI: 65%, n=13). The mean LVEDP for the whole cohort (n=20) was 29±4 mmHg (intervention group: 28±3 mmHg vs. control group: 31±5 mmHg; p=0.1). The LVEDP dropped from 28±3 to 16±2 mmHg in the glyceryl trinitrate + furosemide group (p <0.01) but remained unchanged in the control group. The median dose of glyceryl trinitrate required to produce ⩾ 20% reduction in LVEDP in the intervention group was 200 µg (range: 100-800). One patient experienced asymptomatic decline in systolic blood pressure to below 90 mmHg. There was no correlation between LVEDP and left ventricular ejection fraction.
Conclusion:
The administration of glyceryl trinitrate plus furosemide in patients with elevated LVEDP following primary percutaneous coronary intervention for STEMI safely reduces LVEDP.
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