Atrial Fibrillation

In her response to a reader’s question about clot prevention in a patient with systemiclupus erythematosus (SLE) and anticardiolipin antibody syndrome,Dr Bonnie Bermas recommends warfarin (CONSULTANT, September 15, 2003,page 1329).

Q:How frequently does hypertension occur in association withobstructive sleep apnea (OSA), and how is OSA best treated?

Heart failure statistics are daunting:550,000 new cases each year, a 1-yearmortality rate of nearly 20%, and annualdirect and indirect costs that total $24.3billion.1 The diverse etiology of heartfailure and the complex, progressivecourse of the disease can make treatmentdecisions daunting as well.

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.

A 54-year-old man with a history of type 2 diabetes, hypertension, and coronaryartery disease with angina presents to the physician’s office withchest pain. The pain began 3 hours earlier and is associated with diaphoresisand dyspnea. Examination results are unremarkable, except for diaphoresis.A 12-lead ECG reveals normal sinus rhythm with large R waves and horizontalST-segment depression in leads V1 through V3. The patient is given nitroglycerin,aspirin, heparin, morphine, and a &#946-blocker for noninfarction acutecardiac ischemia and transferred to the local emergency department (ED).

Theophylline has numerouswell-documented and clinicallysignificant drug interactions.Several diseases alsoaffect theophylline clearance.Here, I provide examples of drug anddisease interactions that are most relevantto office practice.

A 60-year-old woman reportsthat she has felt intermittent“fullness” in her face for the past day.This sensation is present when sheis supine on the examination table.She denies shortness of breath, dysphagia,and chest discomfort. Thepatient has a 25 pack-year history ofcigarette smoking.

An 84-year-old woman with hypertension and type 2 diabetes mellitus isbrought to the emergency department (ED) after an episode of nearsyncope.When emergency medical service personnel initially assessed her,blood pressure was 96/60 mm Hg and heart rate was “slow”; however, shehad no symptoms.

A 74-year-old man with a history ofatrial fibrillation presents to hisprimary care physician with dyspneaof 4 days’ duration. The dyspnea developedwhile he was walking as partof his recovery from back surgery forspinal stenosis 1 month earlier. Hebecame progressively short of breathand was unable to carry out his exerciseprogram.

A 56-year-old man with insulin-dependent type 2 diabetes is hospitalized foroperative debridement of an ulcer on his left heel. During the preoperativeevaluation, atrial fibrillation (AF)-with a ventricular rate of 130 beats perminute-is detected.

A42-year-old man with a history of hypertension presents to an outpatientclinic with chest pain that began the day before, after he had worked outat his health club. The discomfort increases when he walks and worsenssomewhat with inspiration. No associated symptoms are noted. Results of aphysical examination are normal; no chest wall tenderness is evident. Becausecertain features of the presentation suggest an acute coronary syndrome, a12-lead ECG is obtained, which is shown here.

A 78-year-old man complains that he has not “felt well” for several months. Hismajor symptom is profound morning stiffness and achiness, especially in theshoulders and hips. In addition, he has little energy and has difficulty in completingeven routine daily activities.

An 88-year-old woman is admitted for severe dyspnea thathas worsened over the past month. Dyspnea on exertionis now elicited by everyday activities, even walking acrossthe room. Orthopnea and paroxysmal nocturnal dyspneahave progressed to the point that she has been unable tosleep at all the past several nights. She also tires very easilyand thinks her ankles are more swollen than previously.She denies chest pain or pressure.

A 24-year-old woman who is 14 weeks pregnant with her first child is heterozygousfor factor V Leiden. The patient is healthy, has no chronic medical conditions,and takes no long-term medications.

A vigorous 61-year-old man presents for a preemployment physical examination.He has no symptoms of angina pectoris or congestive heart failure (CHF).

A 76-year-old woman presents with chest pain-which she describes as“muscle tightness”- that began when she awoke in the morning. Thepain is constant, exacerbated by deep inspiration, and accompanied by asubjective sense of slight dyspnea; she rates its severity as 3 on a scale of1 to 10. She denies pain radiation, nausea, diaphoresis, palpitations, andlight-headedness. Her only cardiac risk factors are hypertension and a distanthistory of smoking.

A30-year-old man complains of chest pain, dyspnea, fever, and nonproductivecough that began earlier in the day. The pain is constant and does notdiminish with rest; it worsens somewhat with deep inspiration and has localizedto the left chest. The patient has had no nausea, vomiting, or abdominal pain.He has been immobile for several years secondary to spinal cord disease buthas no history of cardiopulmonary disease.

PITTSBURGH -- For women with HER2-positive, advanced-stage breast cancer, the time to disease progression may be doubled by adding Tykerb (lapatinib) to Xeloda (capecitabine) chemotherapy, according to a study that was halted early.

ERLANGEN, Germany -- Gleevec (imatinib mesylate), the cancer drug, may be useful in blocking the pathways involved in systemic sclerosis, according to researchers here.

IRVINE, Calif.-- Methamphetamine users may develop carotid artery dissections, leading to a severe stroke, an effect also seen in cocaine users, according to researchers here.

OAKLAND, Calif. -- HIV-infected patients having surgery were more likely to develop post-op pneumonia or to die within 12 months than matched non-infected patients, researchers here reported.

OAKLAND, Calif. -- HIV-infected patients having surgery were more likely to develop post-op pneumonia or to die within 12 months than matched non-infected patients, researchers here reported.

SAN ANTONIO, Dec. 19 -- New biologic agents are proving useful in breast cancer treatment, but optimizing therapy requires careful attention to adverse event risk.

TORONTO -- For patients with fluid-retaining conditions, the simple act of lying down in bed at night may cause a fluid shift to the upper body that results in obstructive sleep apnea, a small study here suggested.

TORONTO -- For patients with fluid-retaining conditions, the simple act of lying down in bed at night may cause a fluid shift to the upper body that results in obstructive sleep apnea, a small study here suggested.

ROCKVILLE, Md. -- The FDA announced today it had narrowed the indications for Trasylol (aprotinin injection), a drug used control bleeding during heart surgery, partly because of belatedly revealed risks of death or serious kidney damage.

ROCKVILLE, Md. -- The FDA announced today it had narrowed the indications for Trasylol (aprotinin injection), a drug used control bleeding during heart surgery, partly because of belatedly revealed risks of death or serious kidney damage.

SAN ANTONIO -- Breast cancer patients may get similar benefit with less toxicity from adjuvant chemotherapy containing Taxotere and Herceptin but not the cardiotoxic anthracycline Adriamycin, researchers said.

SAN ANTONIO -- Breast cancer patients may get similar benefit with less toxicity from adjuvant chemotherapy containing Taxotere and Herceptin but not the cardiotoxic anthracycline Adriamycin, researchers said.

PHILADELPHIA -- Performance measures for hospitals adopted by Medicare and the Joint Commission on Accreditation of Healthcare Organizations may only be loosely related to patient outcomes.