Sharing together: Part IV

This video contains:

  • Targets of the pharmacological approach of hypertension
    By Atul Pathak, Professor of Cardiology and Clinical Pharmacology and RHC 2013 Faculty member
  • Issues with future therapies for resistant hypertension: which key paper should we consult?
    By Jean Marco, Honorary Chairman of PCR

Comments

Mon, 2013-02-04 14:49
john adan

Take beta blocker, RAS inhibitor and spironolactone for adrenaline, angiotensin and aldosterone.

Drink water for vasopressin. Make your BP 110/70, cholesterol 122 and live 100 years.

Mon, 2013-02-04 14:51
rhc

You forget an essential key point: don't drink water but drink one glass of french red wine every day!

Mon, 2013-02-04 17:48
Pathak

You are right! The whole renal denervation approach has shown that if you want to control BP the simple association of a RAS blocker added to a Calcium channel blocker with a beta blocker plus spironolactone is effective in controlling BP. Finally renal denervation is pressurizing doctors, and resahping the way we are managing BP. This innovation is leading doctors tyo

Mon, 2013-02-04 15:01
Sayed Nour

Thank you very much for enriching the discussion fro this interesting subject.Please find below our opinion regarding new therapeutic approach for RH. Movies are available in case of interest.
N.B. The trouser was successfully used in two life-threatening situations of RH patients, including one postpartum RH.

++++++++++Newsletter RHC - Sharing together - PART IV +++++++++++++

RH is an endothelial dysfunction disease, most commonly associated with normal cardiac function (type B) and less frequently with heart diseases (type A) or normal persons (type C), e.g. postpartum RH.

Unfortunately, current RH management remains insufficient most probably due to:
o Drawbacks of current RH therapeutic options.
o Controversial results of current CAD that could not adapt with the different criteria between the right and left heart circuits, regarding Biophysics and physiopathological behavior .
Proposal
Clinical applications of shear stress-°©‐mediated endothelial function enhancement, using new generations of pulsatile CAD.
This could be done safely through the natural stock of endothelium and blood volume at the right heart side, which represents a physiological backup in case of hemodynamic disorders if stimulated with the proper CAD.

Devices:
o An intrapulmonary pulsatile catheter, which could be introduced intravenously and percutaneously, in emergency setting.
o A pulsatile suit concept, which includes pulsatile: trouser, vest, belt, mask, or local cuffs, could improve RH on a long-°©‐term as well as short term.

Therapeutic targets:
o On short-term: Reduction of vascular resistances, improvement of hemodynamic and organs microcirculations and to avoid threatening conditions, e.g. hypovolemia, surgical risks, etc. Reductions of vascular resistances are currently, available with pharmacological supports; and/or with interventional or surgical procedures, including installations of mechanical or biological cardiac assist devices (CAD).
o On short-term: Restoration and preservations of endothelial function.

Experimental studies:
Pediatric animal models (piglets):
o An intrapulmonary small balloon catheter, pulsated in higher frequency to heart rate ≥ 110 bpm, was tested in acute PAH and acute MI models (after permanent ligation of the LAD).
o A pulsatile trouser was pulsated in a lower frequency to heart rate (40 bpm), and in a low pressure (<0.8 bar), was tested in Acute RVF (acute disruption of the pulmonary valve).

Systemic and pulmonary pressures as well as resistances were significantly dropped after few minutes of devices pulsations (≈ 10 min & ≈ 20 with catheter & trouser pulsations, respectively)

N.B. We should emphasize, there no associated pharmacological supports in all the pulsatile groups.

Volunteers:
o The pulsatile trouser was applied in a hypertensive patient (medical doctor). He was on ACE inhibitors and represented with 170/120 mmHg: after 20 min of pulsatile trouser application (synchronized with the diastolic phase, low pressure (1.4 bars): BP became 120/80 mmHg. The patient, had no dizziness or any others signs of hypovolemia.

Limitations:
o Approval by the Healthcare Authority, the trouser was recently approved for clinical studies: e.g. Congestive HF (type A), diabetes (type B).
o Prototypes performances: e.g., the inner layer of the pulsatile trouser, which should be made of elastic materials (e.g. Neoprene, etc) to increase the shear stress effect at the superficial capillary systems, and cutaneous baroreceptors, are still debated.

Conclusions

The pulastile trouser and/or catheter represent a cost-°©‐effective, nearly physiological therapy for RH patients at least in emergency situations.

Sayed Nour MD, PhD

References

1. Nour S, et al. The forgotten driving forces in right heart failure: concept and device. Asian Cardiovasc Thorac Ann 2009;17:525-°©‐30. 2. Nour S. Nouvelle Théorie Hémodynamique “Flux et Rythme”: Concept et applications précliniques en utilisant des nouveaux dispositifs d’assistance circulatoire. PhD (High Hon), Therapeutic Innovations-°©‐ University of Paris XI (France), 2012. 3. Nour S et al. Forgotten driving forces in right heart failure (Part II): Experimental study. Asian Cardiovasc Thorac Ann 2012;20:646-°©‐657. 4. Nour S. Flow and Rate: Concept and clinical applications of a new hemodynamic theory. In: Misra AN (ed) Biophysics. Intech, Rijeka, 2012:19-°©‐76.

Mon, 2013-02-04 17:45
Pathak

Take the time to browse different consensus paper's you will see that according to countries the patient selection and indication are not always the same ! Maybe it's time to sit around a table and find a common consensus paper !

Sat, 2013-02-23 13:30
Dr. Sayed Nour

Regarding our previous comment, an eminent Professor of Biophysics from our group, kindly reminded me about the unclear explanation between low-pressure garment and 1.4 bars, which is impossible to apply on a human body. In our experience we were focusing on the pressure gauge of the pneumatic generator that could be connected to high-pressure air sources like in hospital settings, which is around 4 bars, or high pressure bottle around 22 bars, then to be delivered through low-pressure valves into hoses connected to the pulsatile suit device. We found that a 1.4 bars maximum was enough to fill and pulsate gently the infradiaphragmatic compartment of the suit (trouser + belt) in a muscular heavy built adult volunteer with good results.
As been mentioned previously in our several publications, the induced pressure at the human body must be like a gentle massage. This can be determined by the therapists and controlled by the security features equipments of the pulsatile suit (e.g. autorelease valve). It is always difficult to identify exactly the requested suit pressure due to several factors: individual reasons e.g. morphology (muscular, adults, paediatrics, etc.), indications; and technical reasons: energy losses inside the circuit (e.g. types and length of hoses), suit materials etc. Most importantly we need specific sensors to identify the exerted suit’s pressure upon the body, which could be interesting for academic research purposes but less practical and cost effective, in clinic.