Mental stress can trigger myocardial ischemia, but the prevalence of mental stress–induced ischemia in congestive heart failure (CHF) patients is unknown. We characterized mental stress–induced and adenosine-induced changes in myocardial perfusion and neurohormonal activation in CHF patients with reduced left-ventricular function using SPECT to precisely quantify segment-level myocardial perfusion. Methods Thirty-four coronary artery disease patients (mean age ± SD, 62 ± 10 y) with CHF longer than 3 mo and ejection fraction less than 40% underwent both adenosine and mental stress myocardial perfusion SPECT on consecutive days. Mental stress consisted of anger recall (anger-provoking speech) followed by subtraction of serial sevens. The presence and extent of myocardial ischemia was quantified using the conventional 17-segment model. Results Sixty-eight percent of patients had 1 ischemic segment or more during mental stress and 81% during adenosine. On segment-by-segment analysis, perfusion with mental stress and adenosine were highly correlated. No significant differences were found between any 2 time points for B-type natriuretic peptide, tumor necrosis factor-α, IL-1b, troponin, vascular endothelin growth factor, IL-17a, matrix metallopeptidase-9, or C-reactive protein. However, endothelin-1 and IL-6 increased, and IL-10 decreased, between the stressor and 30 min after stress. Left-ventricular end diastolic dimension was 179 ± 65 mL at rest and increased to 217 ± 71 after mental stress and 229 ± 86 after adenosine (P < 0.01 for both). Resting end systolic volume was 129 ± 60 mL at rest and increased to 158 ± 66 after mental stress (P < 0.05) and 171 ± 87 after adenosine (P < 0.07), with no significant differences between adenosine and mental stress. Ejection fraction was 30 ± 12 at baseline, 29 ± 11 with mental stress, and 28 ± 10 with adenosine (P = not significant). Conclusion There was high concordance between ischemic perfusion defects induced by adenosine and mental stress, suggesting that mental stress is equivalent to pharmacologic stress in eliciting clinically significant myocardial perfusion defects in CHF patients. Cardiac dilatation suggests clinically important changes with both conditions. Psychosocial stressors during daily life may contribute to the ischemic burden of CHF patients with coronary artery disease.

PVBs provided excellent analgesia with significant opioid sparing in this pilot series of 30 patients with HALN. Utilization of multimodal analgesia incorporating PVB is recommended for patients presenting for HALN.

A 24-year-old female with a history of ulcerative colitis underwent colectomy. The patient received an ineffective transversus abdominis plane (TAP) block with liposome bupivacaine (Exparel) intraoperatively and was started on a hydromorphone patient-controlled analgesia 5 hours after the TAP block, which did not relieve her pain. A continuous thoracic epidural (CTE) was then placed after blood levels of bupivacaine were drawn, and the patient immediately experienced significant pain relief. The combined use of liposome bupivacaine and bupivacaine CTE infusion in the postoperative management of this patient demonstrated no safety concerns, provided excellent analgesia and plasma concentrations of bupivacaine remained far below toxic levels.

A 66-year-old man, a known intravenous heroin user for 45 years, presented to Baylor University Medical Center (BUMC) in May 2001 with a painful left upper arm after falling off a crate. A fractured left humerus was diagnosed, the arm was placed in a sling, and the patient was sent home. Upon reviewing the radiograph the following day, the attending radiologist noticed abnormal lung findings and called the patient, who reported a 1-to 2-month history of dyspnea on exertion. Several months earlier the patient was found to have an ejection fraction of 30% by echocardiogram, as well as severe chronic pulmonary obstructive disease. A partial gastrectomy had been performed many years previously, and a bypass operation had been done in one leg. He had no known allergies. The only medicine he