Waheib A Bamatraf is a cardiologist at Saud Al-Babtain Cardiac center in Dammam, Saudi Arabia. He has a passion for patient care as a whole human being rather than a diagnosis, enjoys research and believes that learning is an endless process.

Background: The cornerstone of the management of cardiogenic shock (CS) is

inotropic agents. However, they have a drawback of increasing heart rate (HR) which is considered an independent predictor of mortality. Ivabradine has a potential of reducing HR without interfering with positive effects of inotropes.

Case: A 37 years old man known case of DM, presented with extensive anterior STEMI. Primary PCI was done to LAD. During the procedure he developed recurrent VF for which DC shocks were given, CPR was done for 4 minutes. He was started on mechanical ventilation. Subsequently IABP was inserted along with introduction of Dopamine, Noradrenaline and Adrenaline at maximum doses. Post intervention his systolic blood pressure (SBP) was between 90-100 mmHg and HR was 125-140 bpm and tissue hypoperfusion was evident. Echo showed LVEF 35% with no mechanical complications. After 24 hours from admission, due to significant tachycardia, Ivabradine was initiated. The next day, significant improvement in HR 80-100 bpm and improvement in SBP 110-120 mmHg were noted; which allowed discontinuation of inotropes and extraction of IABP. He was discharged from the hospital after 6 days of admission. No adverse effects were documented during hospitalization.

Discussion: The pharmacological management of CS has not evolved for long time. It is hampered by difficulty in conducting RCTs in such critical unstable patients. Ivabradine is currently not used in CS due to lack of supporting evidence, despite that sound understanding of physiological and pharmacological aspects of CS and inotropes favors a possible role for controlling heart rate without negative inotropy.

Conclusion: Concomitant use of Ivabradine with maximal inotropes didn’t result in adverse effects, actually, favorable hemodynamics were noted within 24 hours of initiation in our single case reported here. Further research may be warranted to explore feasibility of Ivabradine use in such clinical setting.

Sekib Sokolovac is the Head of the Governmental Organization in Bosnia and Herzegovina. He is graduated from Medical Faculty Sarajevo in 1983. He is awarded as the specialist in Internal Medicine in 1994. He has done Master of Science in 1998. He was awarded PhD in 2004. Mr.Sokolovac is a fellow of University California Irvine, Oxford, AKH Vienna. He is specialist in both Cardiology and Rheumatology. He had started working in University Clinical Center Sarajevo from 1990 in the Department of Cardiology. He is the Director of Excellence Center for Arterial Hypertension. Vice-President of the Association of Cardiologists of Bosnia and Herzegovina, ESC Nucleus Member of Working Group on Pulmonary Circulation and Right Heart, President of the Working Group on Arterial Hypertension of UKBiH and He served as the Editorial Board Member of Rheumatology International Journal, European Journal of Rheumatology, Mediterranean Journal of Rheumatology. He had published many papers and books. He also have done many research projects in his field.

Introduction: Ajmalin is a class Ia antiarrythmic agent that blocks the sodium ion channels. This agent is mainly used in detecting Brugada syndrome, but also it has effects on prolonging the action potentials and provoking the lenghtening of the QT interval. The final result is in the slowing of the heart beat.

Material and Methods: This case report showing paroxismal supraventricular

tachycardia in a 55y/o male patient who suffered from myocardial infarction one month ago. The patient received i.v. and oral beta blockers, Ca-channel antagonists, Propafenone, Amiodarone,Xylocain , sotalol, 2grams of Magnesium i.v. There was no

efficiancy, except the minimum one with magnesium that slowed the heart rate from 160 per minute to 130/min.

Result: ECG after i.v. bolus of 50mg/10ml of ajmalin.

 

Conclusion: This is the great example of our expirience with ajmalin in a treatment of paroxismal tachycardia. We have been using ajmalin with a great efficiacy for more than 25 years or so. We recommend to all practitioners to consider using this very efficient antiarrhythmic drug.

Abdullah Orhan DemirtaÅŸ has completed his MD at the age of 30 years from Health Science University Adana Health Practise and Research Center. He is the

resident doctor of Health Science University Adana Health Practise and Research Center. He has published more than 5 papers in reputed journals and has been

serving as an editorial board member of repute.

Purpose: Recently, a significant increase in the frequency of the usage of cardiac implantable electronic devices (CIED) in cardiology. Pneumothorax (PTX) is one of the most important complications that is met while placing CEID. There is not a distinct data that is shown between body mass index (BMI) and clavicle length in the patients with PTX. In our particular study, we aim to investigate if there is a relationship between PTX and clavicle length and BMI in the patients with CIED.

 

Method: We included 1702 patients who had been placed CIED for any reason retrospectively between the years 2008 and 2018. We recorded demographic and procedural data in addition to clavicle length and BMI/clavicle length (PTX index).

 

Findings: We included 1568 patients without PTX and 34 (2.2 %) patients with PTX in our study. When anatomical distances were compared, it was found that clavicle proximal distal, angulus mandibular clavicle middle region, angulus mandibular clavicle distal tip distances decreased significantly in patients with PTX and PTX index increased significantly. The distance

between angulus mandibular clavicle tip (OR:0.811) and pneumothorax index (OR:8.014) were determined as the variables for pneumothorax. When the cut-off value for PTX index was taken as 1.67, it was observed that PTX was predicted with 70 % sensitivity and 62 % specificity.

 

Result: The length of clavicle and BMI can provide the operator with prognosis about the PTX development in the patient.

Armin Attar is an interventional cardiologist from Shiraz University of Medical Sciences. He has founded Traditional and Advanced Heart Approaches (TAHA)

clinical trial group and have guided several investigations in the field of primary prevention of cardiovascular diseases. He has also a Ph.D. on stem cell biology

and technology and his main focus of research is mesenchymal stem cells in that field.

Statement of the Problem: In the new ACC/AHA hypertension guidelines,

individualized cardiovascular risk assessment is emphasized and aggressive

management of blood pressure using a 10-year risk of cardiovascular events of

more than 10% is recommended. However, this decision is being criticized as

not being based on a trial results. Methodology & Theoretical Orientation: To

perform a secondary analysis, we obtained the data of Systolic Blood Pressure

Intervention Trial (SPRINT) from NHLBI Data Repository Center. In SPRINT,

an open-label trial, non-diabetic participants with SBP of ≥130 mmHg were

randomized to intensive and standard treatment groups with SBP targets of <120 and <140mmHg respectively. The primary composite outcome was myocardial infarction, and other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Here, we have analyzed data from participants without CVD and chronic kidney disease aged below 75 years categorized based on baseline 10 years Framingham cardiovascular (<10% [low risk]; ≥10 [intermediate or high risk].

 

Findings: A total of 4298 patients were included in the analysis. Throughout the 3.12 years of follow-up, the mean SBP level was 122.76±8.19 and 135.31±6.48 mmHg in the intensive and standard treatment groups, respectively (average difference, 12.55 mmHg; P< 0.001). In general, patients with a risk above 10% showed a significant benefit (HR with intensive treatment, 0.43; 95% CI, 0.28 to 0.66; P< 0.001). As is shown in the Figure this benefit was not affected by sex, age, BP level, race, and consumption of aspirin or statins. However, intensive BP reduction was not useful for those at low risk (0.75% per year vs. 0.57% per year; HR, 1.14; 95% CI, 0.55 to 2.38; P=0.714).

 

Conclusion & Significance: Intensive SBP reduction is beneficial for primary prevention of cardiovascular morbidity and mortality in non-diabetic patients with more than low cardiac risk (above 10%).

Sawsan Al Yousef, MD, CABP, FCCP, Assistant Professor king Saud Bin Abdulaziz University and Health Science, Clinical and Research Pediatric Critical Care fellowship from University of Western Ontario, Canada, 2001, Clinical Pediatric Respiratory, University of Toronto, Canada, Arab and Saudi Board of Pediatrics, 1997.Currently Appointed as Consultant Pediatric Intensive Care and Pulmonory at King Fahad Medical City(KFMC) ,Chairperson of Post Graduate simulation department at Center for research , Education, Simulation enhance training CRESENT)KFMC, Director of Saudi Commissioner for Health specialty for PICUFellowship Examination committee, Saudi Arabia.

Simulation is a technique to replace or amplify real experiences in an interactive setting. Simulation-based learning (SBL) applies this, through the use of role play, simulated patients, part-task trainers, virtual reality devices and electronic manikins. Patient safety priorities are at the forefront of health providers' concerns and this has driven a more consultant-led service. The see one, do one, teach one philosophy has hopefully been and certainly should be, eliminated. SBL can take place without exposing patients to risk, at the speed of the learner, with immediate feedback and the ability to adapt to the learner in a completely flexible way. Perhaps this is best summarized by saying that simulators have the potential to take the early and dangerous part of the learning curve away from patients. Benefits of medical simulation includes safe environment, mistake forgiving, trainee focused vs. patient focused, controlled, structured, proactive clinical exposure, reproducible, standardized, debriefing, deliberate and repetitive practice. Simulation has rapidly evolved as a learning tool and technology over the past 15 years, and has been shown to be an effective method for teaching. Despite this, the field of cardiovascular medicine is still in the primitive stages of adopting simulation. The reasons cited for this include: the high cost of simulators, a dearth of didactic curricula to accompany the psychomotor skill learned on a simulation, the wide variability and/or lack of consistency that exists among the simulation platforms, and a complete absence of large trials showing that this expensive technology actually improves operators' skill in the angiography suite and presumably enhances patient outcomes. Despite all this, the ACGME now mandates that cardiovascular fellowship training programs must have simulation as part of fellow training. Cardiac simulation training ranges from as simple as training on listening to normal and abnormal heart sounds, differentiating different types of heart murmurs, interpreting ECG findings, utilizing high fidelity manikins for different cardiac scenarios such as heart failure and cardiogenic shock apply team work as crew resource management, practicing transthoracic echocardiogram plus transoesophegeal echo (TEE), cardiac catheterization and central line insertion up to different cardiac interventional procedures. On June 2017- May 2018, we conducted once per month a one day simulation cardiac course for pediatric residents whom had attended different simulation courses at CRESENT, KFMC. All candidates went through pre course knowledge and clinical skills evaluation followed by the end of the day with post course knowledge and clinical skills evaluation similar to the pre course.125 candidates were involved, 100% of the candidates had significant improvement in their knowledge and skills at post course test compared to pre course and non had declined in their scores beside 100% of them found these courses are enjoyable, safe, not stressful and very useful training methods, 97% enjoyed it mostly because it is repetitive and mistakes are forgiven with zero hazards to patients.100% feels video debriefment following cardiac medical scenarios is very helpful asit clarify areas for improvement much better than conventional training. In conclusion, although cardiac Simulation courses is expensive but it plays important role in patient safety expensive but it plays important role in patient safety so at the end it is cost effective so would encourage to make it mandatory in the curriculum for cardiac residents and fellows.