Cirrhotic cardiomyopathy:Isn't stress evaluation alwaysrequired for the diagnosis?

AIM:To describe the proportion of patients with cirrhotic cardiomyopathy(CCM) evaluated by stress echocardiography and investigating its association with the severity of liver disease.METHODS:A cross-sectional study was conducted.Cirrhotic patients without risk factors for cardiovascular disease were included.Data regarding etiology and severity of liver disease(Child-Pugh score and model for end-stage liver disease),presence of ascites and gastroesophageal varices,pro-brain natriuretic peptide(proBNP) and corrected QT(QTc) interval were collected.Dobutamine stress echocardiography(conventional and tissue Doppler imaging) was performed.CCM was considered present when diastolic and/or systolic dysfunction was diagnosed at rest or after pharmacological stress.Therapy interfering with cardiovascular system was suspended 24 h before the examination.RESULTS:Twenty-six patients were analyzed,17(65.4%) Child-Pugh A,mean model for end-stage liver disease(MELD) score of 8.7.The global proportion of patients with CCM was 61.5%.At rest,only 2(7.7%)patients had diastolic dysfunction and none of the patients had systolic dysfunction.Dobutamine stress echocardiography revealed the presence of diastolic dysfunction in more 6(23.1%) patients and of systolic dysfunction in 10(38.5%) patients.QTc interval prolongation was observed in 68.8%of the patients and increased pro-BNP levels in 31.2%of them.There was no association between the presence of CCM and liver impairment assessed by Child-Pugh score or MELD(P= 0.775,P= 0.532,respectively).Patients with QTc interval prolongation had a significant higher rate of gastroesophageal varices comparing with those without QTc interval prolongation(95.0%vs 50.0%,P= 0.028).CONCLUSION:CCM is a frequent complication of cirrhosis that is independent of liver impairment.Stress evaluation should always be performed,otherwise it will remain an underdiagnosed condition.

Possible convulsion and electroencephalographic abnormality in a patient taking long-term oral clarithromycin:A case report

BACKGROUND Clarithromycin is a macrolide antibiotic commonly prescribed to patients with upper respiratory and otolaryngological infections.Neuropsychiatric adverse effects of clarithromycin include agitation,insomnia,delirium,psychosis,and seizure.CASE SUMMARY A 52-year-old man was admitted to our hospital with a convulsion.He had>10-year history of clarithromycin intake for chronic sinusitis.One week before admission,he started to take diltiazem for angina pectoris.On admission,his convulsion subsided.His electroencephalography showed frontal intermittent rhythmic delta activity.One week after he ceased clarithromycin,his electroencephalographic abnormalities disappeared.We suggested that the patient developed convulsions due to increased blood levels of clarithromycin caused by oral administration of diltiazem,which is involved in CYP3A metabolism.CONCLUSION Clarithromycin has a relatively high safety profile and is a frequently prescribed drug.However,there are a few previous reports of clarithromycin-related convulsive disorders.Clinicians should be aware of the drug interaction and rare side effects of seizures.