Atrial Fibrillation

A 20-year-old woman has had several episodes of syncope since she enteredcollege 2 months earlier. Although 1 or 2 episodes were associated with exercise,most were not. All occurred at times of surprise and/or emotional stress:she fainted twice when the bell rang at the end of a test, once after her alarmclock suddenly awakened her in the morning, and once when she received adisturbing phone call from home.

In this compact clinical guide, the author presents detailed prescribing advice forall types of cardiac patients. The first chapters are devoted to the principal classesof cardiac drugs: β-blockers, angiotensin-converting enzyme inhibitors, angiotensinII receptor blockers, calcium antagonists, and diuretics. These chapterscover such topics as indications, contraindications, adverse effects, interactions,dosages, differences between the available agents in a given class, and how tochoose the most appropriate agent from a class for a particular patient. Chapterson the management of the various cardiac disorders-hypertension, angina, acutemyocardial infarction, heart failure, arrhythmias, cardiac arrest, infective endocarditis,and hyperlipidemia-comprise the core of the book. There are also chapterson antiplatelet agents, anticoagulants, and thrombin inhibitors; and the use ofcardiac drugs during pregnancy and lactation. The sixth edition features a newchapter on recent clinical trials, new American Heart Association cardiac arresttreatment algorithms, current hypertension management guidelines, and expandeddrug administration and dosage tables. Numerous tables, charts, algorithms,and graphs accompany the text.

A 62-year-old woman presents with severe, sharp pain in her right mid chestthat worsens when she breathes. The pain began the previous night, shortlyafter she had been awakened by a shaking chill, followed by the sensationof fever. She also has a relatively nonproductive cough of recent onset.

A56-year-old woman with chest pain and emesis is brought to the hospitalby ambulance. En route, the pain resolves after nitrates, morphine,and aspirin are administered.

For 2 days, a 49-year-old man with hypertension and hypercholesterolemiahas experienced light-headedness and fatigue.Based on the presenting ECG, what is the most likely cause of hissymptoms?A. Accelerated junctional rhythm.B. First-degree atrioventricular (AV) block.C. Mobitz type I (Wenckebach) second-degree AV block.D. Mobitz type II second-degree AV block.E. Third-degree AV block (complete heart block).

An 81-year-old man presents with severe Alzheimer dementia. Hishistory includes benign prostatic hypertrophy with 2 transurethralresections. He has a remote history of tobacco use and has not used alcohol excessively. He isotherwise in good health. At the time of his original diagnosis, a cholinesterase inhibitor was notprescribed.

For over 25 years, NSAIDs have been used to treat a variety of pain syndromesand inflammatory diseases. More than 50 million Americanstake these drugs. Unfortunately, control of pain and inflammation is notachieved without an associated cost-namely, GI complications and, to a lesserextent, nephrotoxicity.In an attempt to reduce drug-related toxicity, a new class of selectiveNSAIDs-the COX-2 inhibitors-was introduced in 1999. These selectiveNSAIDs are as effective as and pose less risk of gastric toxicity than nonselectiveNSAIDs.1,2The COX-2 inhibitors are thought to reduce end-organ injury, such as GIulceration, by sparing homeostatic or “constitutive” COX-1 enzyme function.1,2 Incontrast, therapeutic effects result from the inhibition of the “inducible” COX-2enzyme.1,2 Such drug effects target the production of proinflammatory prostaglandinsby COX-2 without interrupting normal cell function mediated by COX-1.2,3

This simple technique can quickly reduce leg edema.

A 66-year-old woman presents tothe emergency department(ED) with exertional dyspnea, generalizedweakness, and orthostaticdizziness; the symptoms startedabout 1 week earlier and have progressedinsidiously. The patient alsoreports diaphoresis and nausea withoutvomiting. She has no chest pain,palpitations, cough, or hemoptysis;she has not had a recent respiratorytract infection. While she is waitingto be admitted, she has an episode ofsyncope.

What are the latest recommendations concerning the treatmentof dermatomyositis?

My patient is a 78-year-old woman with heart failure and type 2 diabetes, bothof which are well controlled.

A 59-year-old woman complainsof progressively worsening bloatingand right upper quadrant pain thatbegan 1 day earlier. She denies feverand trauma. Her medical history includescholecystectomy for cholelithiasisand several emergency departmentvisits for treatment of woundssustained in falls. She has a history ofalcohol abuse, for which she now receivescounseling. However, she admitsthat she occasionally has boutsof heavy drinking.

A24-year-old man who worked ina warehouse is brought tothe emergency department following2 days of high fever with rigors, generalizedweakness, and a purplishrash on both lower legs that had progressedrapidly during the past24 hours. He had become ill about5 days previously, with a worseningsore throat and achiness that did notrespond to over-the-counter lozengesand ibuprofen.

Good nutritional care can improve the short-and longtermcourses of many illnesses that are common in olderadults. The experts who have contributed to this handbookdiscuss the disorders that can seriously affect andbe affected by nutrition, and they present specific recommendationsfor secondary prevention and management.

A 72-year-old farmer is brought by his daughter for a comprehensivegeriatric assessment. His previous history is unremarkable. The patientreports that he has had vivid visual hallucinations, which he calls "visitors." He becomes frightenedand hostile when these incidents occur; on several occasions, he has exhibited violent behavioras persons around him tried to calm him. Although the patient was able to recall each episode indetail, he felt as if he had watched it from a distance and had not been an active participant.

Intermittent, worsening confusion recently developed inan 82-year-old man. His daughter brings him to the officefor evaluation.

A 64-year-old woman complainsof neck fullness that has increased inthe last few months. She has occasionaldyspnea but denies fever, cough, andhemoptysis. Hypertension is well-controlledwith propranolol.

Which antithrombotic regimen is most appropriate for apatient with systemic lupus erythematosus and anticardiolipinantibody syndrome who has had a previous infarct?

A 75-year-old man with coronaryartery disease presents to the emergencydepartment with abdominalpain and light-headedness. The painbegan as a dull ache 4 days earlierand recently became considerablyworse. The patient denies recenttrauma, fever, nausea, vomiting, and diarrhea.

Use the mnemonic “ALPS” (Amiodarone,Lidocaine, Procainamide, Sotalol)to remember the drugs recommendedin the Advanced Cardiac LifeSupport protocol for the treatment ofstable ventricular tachycardia; theECG complexes in this arrhythmiaresemble mountains.

For more than 30 years, serumdigoxin concentrations (SDCs)have been monitored toensure safe, effective therapy.1,2Although the therapeuticrange for SDCs is often listed as either0.8 to 2.0 ng/mL or 0.5 to 2.0ng/mL, the results of clinical trials inthe 1990s suggest an upper limit of1.0 ng/mL for treatment of heart failure.3-11 An upper limit for the SDC of1.0 ng/mL is also recommendedfor patients who have heart failureand atrial fibrillation with rapid ventricularresponse.

A 75-year-old man with a 120-pack-year smoking history has dyspnea on exertion(eg, when he walks more than 3 blocks or climbs 1 flight of stairs) butnot when he is at rest or asleep. His symptoms have progressively worsenedover the past 3 to 4 years and have been accompanied by a 20-lb weight loss.

Branch WT Jr (ed)OFFICE PRACTICE OF MEDICINE (ed 4)Philadelphia, WB Saunders Company, 2003, 1387 pages, $89.95 hardcover

A 27-year-old man is referred by an occupational health clinic for evaluation ofa heart murmur. The murmur was detected during a company-mandated examinationfor a flu-like illness that had caused him to miss several days of work.Before the onset of this illness, he had felt well and had no unusual complaints.He denies symptoms of congestive heart failure.

On her eighth day in the hospital for acute pulmonaryembolism, an 88-year-old woman complains of nauseaand abdominal pain and fullness of 12 hours’ duration.The pain is localized to the mid epigastric area and radiatesinto the right lower quadrant. The patient deniesvomiting, melena, and dysuria; she has refused to eat allday.

Q:Based on the latest evidence, what constitutesoptimal management and follow-up for patientswith asymptomatic carotid stenosis?

In recent years, the number of patients with chronic heartfailure has been steadily increasing; this trend reflects thegrowing population of myocardial infarction survivors andpersons over age 65. Many of these patients are evaluated,treated, and followed up in an outpatient setting. This textprovides an in-depth, hands-on approach to the office-baseddiagnosis and management of heart failure. Chapters aredevoted to history taking; economic burden of heart failure;evaluation of dyspnea, edema, palpitations, and ventricularfunction; coronary artery disease and congestive heart failure(CHF); hemodynamic evaluation; exercise performanceevaluation; patient education; drug therapy for symptomaticCHF; assessment and treatment of arrhythmias; biventricularpacing; established, alternative, and emerging therapies;and diastolic heart failure. Echocardiograms, ECG strips,venograms, patient questionnaires, algorithms, diagrams,charts, and tables appear throughout the text.

Q:Should we be prescribing α-blockers to control hypertension in lightof the ALLHAT findings of adverse effects?

A 23-year-old woman has had 2 episodesof syncope during the past month.Her mother witnessed 1 episode inwhich the patient collapsed and lostconsciousness for a few minutes. Sheexperienced tonic-clonic seizure activitybut no subsequent confusion.

A 52-year-old man presented to theemergency department (ED) with a12-hour history of cramping abdominalpain, nausea, vomiting, andwatery, brown diarrhea. Mid upperquadrantpain had begun suddenlythe night before, 1 hour after the patienthad lifted heavy bags of rocks.The GI symptoms persisted with varyingintensity throughout the night.