Atrial Fibrillation

MONTREAL -- A coronary artery calcium score, obtained via CT, can accurately predict the development of atherosclerotic and ischemic disease in asymptomatic patients with type 2 diabetes, according to a report at the American Society of Nuclear cardiology meeting here.

MEMPHIS, Tenn. -- For children with high-risk medulloblastoma, an aggressive approach can boost five-year survival to about 70% from the current 55%, researchers here reported.

ROCKVILLE, Md. -- The FDA has approved a fully implantable mechanical heart, but has limited the use to a subset of heart failure patients unlikely to live for more than a month without the device.

FRESNO, Calif. -- Pumping up the statin dose may decrease the risk for cardiovascular events in patients with coronary disease and metabolic syndrome.

BARCELONA, Spain -- Acenon (perindopril) plus a diuretic was not a winning combination for reducing heart failure deaths, but it may ease symptoms and improve exercise capacity, according to a trial reported here.

The patient was a 40-year-old African American woman, with no significant past medical history, who presented to our medical center with a 4-week history of shortness of breath and lower extremity edema. The onset was progressive and initially occurred only with moderate exertion until about 2 weeks before presentation; at that time, her symptoms had worsened to the point where she experienced shortness of breath at rest. Orthopnea also developed at this time. The patient also reported intermittent palpitations, wheezing, and a dry cough of unknown duration.

ABSTRACT: Subclinical hypothyroidism is associated with elevated low-density lipoprotein (LDL) cholesterol levels and several factors related to atherosclerosis, including increased C-reactive protein levels and impaired endothelium-dependent vasodilatation. However, considerable controversy exists about screening for and treating this thyroid disorder. Thyroxine therapy lowers elevated LDL cholesterol levels in patients whose serum thyroid-stimulating hormone (TSH) concentrations are higher than 10 mIU/L ; thus, most experts recommend treatment for such patients. However, there is no consensus regarding the management of patients with TSH levels of less than 10 mIU/L. Although the evidence supporting treatment of these patients is not compelling, it is reasonable to offer a therapeutic trial of thyroxine to those who have symptoms.

Five days after starting aspirin and warfarin with an enoxaparin bridge for new-onset atrial fibrillation, a 92-year-old man presented with abdominal pain, nausea, and vomiting. The patient appeared ill and was tachycardic. He had dry mucous membranes; pale sclerae; diminished bowel sounds; and a large, tender left lower abdominal mass. Hematocrit was 22% (baseline, 39%); hemoglobin, 6.8 g/dL; blood urea nitrogen, 65 mg/dL; and creatinine, 3.2 mg/dL (baseline, 1.3 mg/dL). His "pre-renal" ratio was 20. These findings were consistent with bleeding and acute renal failure. He also had a supratherapeutic international normalized ratio (INR) of 4.1.

A 62-year-old man presents with a violaceous, nonpruritic eruption that arose 2 weeks earlier on the hands and feet, including the palms and soles, and spread to the arms and legs (Figure 1). Over the past 3 to 4 weeks, he has had malaise, nonproductive cough, and a decline in mental status but no fever, headache, nausea, light-headedness, hemoptysis, or melena.

The optimal approach to subclinical hypothyroidism continues to be debated. Experts disagree over screening for thyroid dysfunction, the threshold TSH level for treatment, and the upper limit of normal of the TSH reference range.

A 62-year-old man presents with a violaceous, nonpruritic eruption that arose 2 weeks earlier on the hands and feet, including the palms and soles, and spread to the arms and legs.

A 64-year-old woman presents with persistent, progressively worsening chest pain and dyspnea of 1 month's duration. She also reports orthopnea, bilateral leg swelling, and weight gain. She denies any history of similar symptoms.

Five days after starting aspirin and warfarin with an enoxaparin bridge for new-onset atrial fibrillation, a 92-year-old man presented with abdominal pain, nausea, and vomiting. The patient appeared ill and was tachycardic. He had dry mucous membranes; pale sclerae; diminished bowel sounds; and a large, tender left lower abdominal mass. Hematocrit was 22% (baseline, 39%); hemoglobin, 6.8 g/dL; blood urea nitrogen, 65 mg/dL; and creatinine, 3.2 mg/dL (baseline, 1.3 mg/dL). His "pre-renal" ratio was 20. These findings were consistent with bleeding and acute renal failure. He also had a supratherapeutic international normalized ratio (INR) of 4.1.

To what do you attribute symptoms of rash and fever in: a man with type 2 diabetes; a woman with systemic lupus erythematosus; a previously healthy girl.

An 82-year-old man presents with shoulder pain resulting from a fall the day before. He has had intermittent episodes of light-headedness, chest pain, and "flutterings in the chest" over the past week--including one this morning. Episodes last about 2 hours and resolve spontaneously. He denies any loss of consciousness, weakness, or worsening of symptoms with exertion. He also denies headache, abdominal pain, and other injuries. His medical history includes coronary artery disease (treated with bypass grafting 10 years earlier); prostate cancer; and chronic lymphocytic leukemia, for which he is receiving chemotherapy.

An 82-year-old man presents with shoulder pain resulting from a fall the day before. He has had intermittent episodes of light-headedness, chest pain, and "flutterings in the chest" over the past week--including one this morning.

Three case studies of patients with fever and rash challenge you to distinguish infectious from other causes and serious from non-threatening.

DALLAS -- Myocardial infarction survivors who have ventricular dysfunction as measured by an ejection fraction of less than 40% should receive implantable cardioverter defibrillators to prevent sudden cardiac death.

ANN ARBOR, Mich. -- When the cumulative bill for ischemic stroke comes due in 2050 it is likely to total .2 trillion, and that's a conservative estimate, calculated University of Michigan researchers.

HOUSTON -- The cardiotoxicity levels of two effective approaches to breast cancer, Herceptin (trastuzumab) for HER2-positive disease and radiation to the left breast, have been newly quantified.

An update on developments in infective endocarditis by addressing a number of questions physicians commonly raise concerning prophylaxis, diagnosis, and management.

DALLAS -- For patients with cardiovascular disease, chronic kidney disease is often a fellow traveler, necessitating more sensitive diagnostic tools than serum creatinine alone.

SAN FRANCISCO -- Even though anticoagulation for atrial fibrillation may boost the chance of an intracranial bleed slightly in older patients, the benefits of the therapy outweigh the risk of a hemorrhage, according to researchers here.

PAMPLONA, Spain -- Severe obstructive sleep apnea more than doubled the risk of a first ischemic stroke in persons over age 70, researchers here reported.

NEW YORK -- Stroke risk trumps age, gender or other history of heart disease in determining which atrial fibrillation patients benefit from anticoagulation, according to revised guidelines issued today by the American College of Cardiology, the American Heart Association, and the European Society of Cardiology.

We describe a case in which a patient received thrombolytic therapy after he presented with a clinical picture consistent with submassive pulmonary embolism (PE). Two months later, a malignant peripheral nerve sheath tumor was diagnosed, and the patient died with metastatic disease. The filling defect in the left main pulmonary artery originally interpreted as PE was in fact a tumor. This case describes an unusual presentation of a rare disease (malignant peripheral nerve sheath tumor) mimicking a submassive PE.

A middle-aged woman is experiencing episodes of chest pain and fatigue. Although stress test results are positive for ischemia, coronary angiography reveals open arteries. What next step would you take?

An 81-year-old Asian woman was at a family function when she briefly complained of a severe headache, then quickly lost consciousness. She was brought to the hospital within 2 hours of symptom onset.

Is the weight gain associated with thiazolidinediones (TZDs) counterproductive to the treatment of diabetes?

A succinct review of hyperkalemia . . . its various causes, clinical manifestations and consequences, ECG findings, and treatment approaches.