Charité Clinical Journal Club by Fred Luft - 19.8.2015

• published: 24 Aug 2015
• views: 1

The N Engl J Med image of the week shows an electrocardiogram at 25 mm/esc. What we observe is that the heart rate is about greater than 120/min, the QRS compleses are narrow, P waves are discernible, and every other beat is directed (in terms of heart axis) somewhere else. The finding means that the cardiac major QRS vector is changing beat-to-beat, a condition called electrical alternans. You are offered acute treatments: revasculariaziaton, pericardiocentesis, pleural centesis, diuretic therapy, and pace-maker insertion. Transplantation of hematopoietic cells from unrelated donors can cure blood disorders but carries a significant risk of acute graft-versus-host disease (GVHD). The risk is higher when the recipient and donor are HLA-DPB1–mismatched, but the mechanisms leading to GVHD are unknown. The HLA-DPB1 regulatory region contains a single nucleotide polymorphism variant, rs9277534, which is associated with HLA-DPB1 expression. We learn that prospective genotyping could avoid mismatching for rs9277534G-linked HLA-DPB1, and would improve outcomes in these patients. Cardiac troponin concentrations are used to identify patients who would benefit from urgent revascularization for acute coronary syndromes. Investigators hypothesized that troponin concentrations might be used in type-2 diabetic patients with stable ischemic heart disease to identify those at high risk for cardiovascular events who might also benefit from prompt coronary revascularization. We learn that troponin is indeed a first-class risk-factor identifier. However, troponin was not helpful in terms of predicting outcomes of revascularization. The surface antigen, CD319 (SLAMF7), is a robust marker of normal plasma cells and malignant plasma cells in multiple myeloma patients. In contrast to CD138 (the traditional plasma-cell marker), CD319/SLAMF7 is much more stable and allows robust isolation of malignant plasma cells from delayed or even cryopreserved samples. Elotuzumab, an immunostimulatory monoclonal antibody targeting SLAMF7, showed activity in combination with lenalidomide and dexamethasone in a phase 1b–2 study in patients with relapsed or refractory multiple myeloma. In this phase-III study, elutuzumab did just that. The next topic is monitoring of fetal ST segment alterations (STAN), a technology that hopefully identifies fetal distress. STAN is a system for fetal surveillance that displays the fetal heart rate (FHR) and information resulting from the computerized analysis of the fetal ECG ST interval. The STAN machine consists of a monitor showing the fetal cardidotocography (CTG) and analysis of fetal ECG continuously. The noninvasive system is attached to the fetus by fetal scalp electrode. In a randomized trial, the use of STAN did not improve obstetrical outcomes. The N Engl J Med review is on ischemic limb gangrene in patients that have large-vessel pulses present. There are two distinct syndromes of microthrombosis-associated ischemic limb injury. Venous limb gangrene can complicate thrombocytopenic disorders that are strongly associated with deep-vein thrombosis, such as cancer-associated disseminated intravascular coagulation and heparin-induced thrombocytopenia. We next learn about these conditions. Our mystery patient is an 8 year-old girl from China, adopted by US parents, with fever, cough, pleural effusion and a protruding chest mass. The child had had nasopharyngeal anomalies that required earlier operations and the placement of a tracheostomy tube. Thus, we can assume that an infectious origin is likely. In the Lancet, we review percutaneous coronary interventional strategies for treatment of in-stent restenosis. We learn that everolimus-labeled stents or the pharmacologically treated balloon strategies are probably best. Patients with acute ST-segment elevation myocardial infarction (STEMI) and multivessel coronary disease have a worse prognosis compared with individuals with single-vessel disease. Should all identified stenoses be addressed at the first identification? A current study from Denmark suggests that fixing all is better than fixing one. Catheter ablation is increasingly used to manage atrial fibrillation, but arrhythmia recurrences are common. Adenosine might identify pulmonary veins at risk of reconnection by unmasking dormant conduction, and thereby guide additional ablation to improve arrhythmia-free survival. Cardiologists assessed whether adenosine-guided pulmonary vein isolation could prevent arrhythmia recurrence in patients undergoing radiofrequency catheter ablation for paroxysmal atrial fibrillation. The results suggest that physicians should consider routinely incorporating adenosine testing. The next study assessed the safety, tolerability, and efficacy of idarucizumab for the reversal of the anticoagulant effect of dabigatran in healthy male volunteers. Since we reviewed the results in N Engl J Med in patients last week, we can bet that idarucizumab reverses dabigatrin.