Background Preterm birth is the major cause of perinatal mortality in the United States. In the past, pregnant women have been recommended to not exercise because of presumed risks of preterm birth. ...Physical activity has been theoretically related to preterm birth because it increases the release of catecholamines, especially norepinephrine, which might stimulate myometrial activity. Conversely, exercise may reduce the risk of preterm birth by other mechanisms such as decreased oxidative stress or improved placenta vascularization. Therefore, the safety of exercise regarding preterm birth and its effects on gestational age at delivery remain controversial. Objective The objective of the study was to evaluate the effects of exercise during pregnancy on the risk of preterm birth. Data Sources MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov , OVID, and Cochrane Library were searched from the inception of each database to April 2016. Study Design Selection criteria included only randomized clinical trials of pregnant women randomized before 23 weeks to an aerobic exercise regimen or not. Types of participants included women of normal weight with uncomplicated, singleton pregnancies without any obstetric contraindication to physical activity. The summary measures were reported as relative risk or as mean difference with 95% confidence intervals. The primary outcome was the incidence of preterm birth <37 weeks. Tabulation, Integration, and Results Of the 2059 women included in the meta-analysis, 1022 (49.6%) were randomized to the exercise group and 1037 (50.4%) to the control group. Aerobic exercise lasted about 35–90 minutes 3–4 times per week. Women who were randomized to aerobic exercise had a similar incidence of preterm birth of <37 weeks (4.5% vs 4.4%; relative risk, 1.01, 95% confidence interval, 0.68–1.50) and a similar mean gestational age at delivery (mean difference, 0.05 week, 95% confidence interval, –0.07 to 0.17) compared with controls. Women in the exercise group had a significantly higher incidence of vaginal delivery (73.6% vs 67.5%; relative risk, 1.09, 95% confidence interval, 1.04–1.15) and a significantly lower incidence of cesarean delivery (17.9% vs 22%; relative risk, 0.82, 95% confidence interval, 0.69–0.97) compared with controls. The incidence of operative vaginal delivery (12.9% vs 16.5%; relative risk, 0.78, 95% confidence interval, 0.61–1.01) was similar in both groups. Women in the exercise group had a significantly lower incidence of gestational diabetes mellitus (2.9% vs 5.6%; relative risk, 0.51, 95% confidence interval, 0.31-0.82) and a significantly lower incidence of hypertensive disorders (1.0% vs 5.6%; relative risk, 0.21, 95% confidence interval, 0.09-0.45) compared with controls. No differences in low birthweight (5.2% vs 4.7%; relative risk, 1.11, 95% confidence interval, 0.72–1.73) and mean birthweight (mean difference, –10.46 g, 95% confidence interval, –47.10 to 26.21) between the exercise group and controls were found. Conclusion Aerobic exercise for 35–90 minutes 3–4 times per week during pregnancy can be safely performed by normal-weight women with singleton, uncomplicated gestations because this is not associated with an increased risk of preterm birth or with a reduction in mean gestational age at delivery. Exercise was associated with a significantly higher incidence of vaginal delivery and a significantly lower incidence of cesarean delivery, with a significantly lower incidence of gestational diabetes mellitus and hypertensive disorders and therefore should be encouraged.
Objectives This study evaluated effects of protease-activated receptor-1 antagonist vorapaxar (Merck, Whitehouse Station, New Jersey) versus placebo among the TRACER (Thrombin Receptor Antagonist for ...Clinical Event Reduction in Acute Coronary Syndrome) study patients with non–ST-segment elevation acute coronary syndromes undergoing coronary artery bypass grafting (CABG). Background Platelet activation may play a key role in graft occlusion, and antiplatelet therapies may reduce ischemic events, but perioperative bleeding risk remains a major concern. Although the TRACER study did not meet the primary quintuple composite outcome in the overall population with increased bleeding, an efficacy signal with vorapaxar was noted on major ischemic outcomes, and preliminary data suggest an acceptable surgical bleeding profile. We aimed to assess efficacy and safety of vorapaxar among CABG patients. Methods Associations between treatment and ischemic and bleeding outcomes were assessed using time-to-event analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using the Cox hazards model. Event rates were estimated using the Kaplan-Meier method. Results Among 12,944 patients, 1,312 (10.1%) underwent CABG during index hospitalization, with 78% on the study drug at the time of surgery. Compared with placebo CABG patients, vorapaxar-treated patients had a 45% lower rate of the primary endpoint (i.e., a composite of death, myocardial infarction, stroke, recurrent ischemia with rehospitalization, or urgent coronary revascularization during index hospitalization) (HR: 0.55; 95% CI: 0.36 to 0.83; p = 0.005), with a significant interaction (p = 0.012). The CABG-related Thrombolysis In Myocardial Infarction major bleeding was numerically higher with vorapaxar, but not significantly different between vorapaxar and placebo (9.7% vs. 7.3%; HR: 1.36; 95% CI: 0.92 to 2.02; p = 0.12), with no excess in fatal bleeding (0% vs. 0.3%) or need for reoperation (4.7% vs. 4.6%). Conclusions In non–ST-segment elevation acute coronary syndrome patients undergoing CABG, vorapaxar was associated with a significant reduction in ischemic events and no significant increase in major CABG-related bleeding. These data show promise for protease-activated receptor 1 antagonism in patients undergoing CABG and warrant confirmatory evidence in randomized trials. (Trial to Assess the Effects of SCH 530348 in Preventing Heart Attack and Stroke in Patients With Acute Coronary Syndrome TRA·CER Study P04736AM3; NCT00527943 )
Spontaneous echo contrast (SEC) is known to be a predisposition to thromboembolism and cerebrovascular accident. The aim of this study was to investigate the risk factors and the consequences of SEC ...in patients who were placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) because of cardiogenic shock.
Between January 2011 and December 2014, 98 patients underwent the insertion of VA-ECMO because of cardiogenic shock in our institution. Transthoracic and transesophageal echocardiography was performed and interpreted by National Board of Echocardiography certified cardiologists. Patients were divided into 2 groups based on the presence or absence of SEC. Clinical data, echocardiographic measurements, and outcomes were compared between the 2 groups.
Of the 98 patients, 22 patients (22%) had SEC on echocardiography. Patients in the SEC group had a lower ejection fraction (8.0% versus 29%; p < 0.001), a lower pulsatility index (defined by systolic blood pressure - diastolic blood pressure/mean blood pressure) while receiving ECMO (0.13 ± 0.14 versus 0.26 ± 0.22; p = 0.009). The SEC group had a higher rate of intracardiac thrombus (46% versus 13%; p = 0.002) and stroke (36% versus 7.9%; p = 0.002). On univariate analysis, intracardiac thrombus, SEC, and low pulsatility were significant risk factors for the development of stroke. On multivariate analysis, SEC was the only independent risk factor for stroke.
SEC on VA-ECMO resulted in an increased risk of intracardiac thrombus and stroke. Maintaining pulsatility while the patient is on ECMO may result in a decreased chance of developing SEC and stroke.
Every year more than 500,000 patients present to the emergency department with cocaine-associated complications, most commonly chest pain. Many of these patients undergo extensive work-up and ...treatment. Much of the evidence regarding cocaine's cardiovascular effects, as well as the current management of cocaine-associated chest pain and acute coronary syndromes, is anecdotally derived and based on studies written more than 2 decades ago that involved only a few patients. Newer studies have brought into question many of the commonly held theories and practices regarding the etiology, diagnosis, and treatment of this common clinical scenario. However, there continues to be a paucity of prospective, randomized trials addressing this topic as it relates to clinical outcomes. We searched PubMed for English-language articles from 1960 to 2011 using the keywords cocaine, chest pain, coronary arteries, myocardial infarction, emergency department, cardiac biomarkers, electrocardiogram, coronary computed tomography, observation unit, β-blockers, benzodiazepines, nitroglycerin, calcium channel blockers, phentolamine, and cardiomyopathy; including various combinations of these terms. We reviewed the abstracts to confirm relevance, and then full articles were extracted. References from extracted articles were also reviewed for relevant articles. In this review, we critically evaluate the limited historical evidence underlying the current teachings on cocaine's cardiovascular effects and management of cocaine-associated chest pain. We aim to update the reader on more recent, albeit small, studies on the emergency department evaluation and clinical and pharmacologic management of cocaine-associated chest pain. Finally, we summarize recent guidelines and review an algorithm based on the current best evidence.
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