Atrial Fibrillation

ABSTRACT: The early signs of diabetic neuropathy can be detected during a routine clinical examination. Inspect patients' feet for deformities and sensory loss, which indicate risk of ulceration. Prolonged poor glycemic control, alcohol abuse, and obesity increase the risk of amputation. Autonomic dysfunction, which can lead to sexual dysfunction and gastropathy, can be detected by measurement of heart rate and blood pressure. A resting heart rate of about 100 beats per minute and a decrease of about 30 mm Hg in systolic blood pressure within 2 minutes of standing are abnormal findings. Electromyography and nerve conduction studies confirm the diagnosis. Improved metabolic control is the main goal of treatment. Analgesics, neuromodulators, and tricyclic antidepressants are effective for managing pain. In patients with autonomic neuropathy, treat the associated symptoms.

A left-handed 84-year-old retired attorney is seen for a routine scheduled visit 5 months after a stroke. The nondominant hemisphere was affected by an embolism that arose in the newly fibrillating left atrium.

ABSTRACT: The Studies of Left Ventricular Dysfunction (SOLVD) trials demonstrated that early intervention in congestive heart failure (CHF) improves survival. However, early CHF is mainly a clinical diagnosis based on New York Heart Association criteria and, until recently, no easy and inexpensive screening test existed. There are now several such tests that employ radioimmunoassays (RIAs) to measure cardiac peptides in a single plasma sample; results help determine the likelihood that CHF is present but do not definitively establish the diagnosis. The vessel dilator RIA is the most specific and sensitive for differentiating persons with mild CHF from healthy ones; intravenous administration of this cardiac peptide hormone has beneficial hemodynamic, diuretic, and natriuretic properties in persons who have CHF. Brain natriuretic peptide (BNP) measured by fluorescence immunoassay is useful in the emergency department, because a result may be obtained in as little as 15 minutes. This assay may indicate CHF; further tests are recommended to define the diagnosis. BNP increases with other causes of dyspnea, including pulmonary hypertension, pulmonary emboli, and renal failure, so it is not specific for CHF. BNP also increases with age, and measured values are higher in women than in men.

A 60-year-old woman with hypertension, diabetes mellitus, and intermittentatrial fibrillation presents with nausea, diaphoresis, dizziness, and globalweakness that has lasted 1 hour. She denies chest pain, dyspnea, syncope,vomiting, diarrhea, blood loss, and headache; there is no vertigo. Medicationsinclude acetaminophen, digoxin, diltiazem, glipizide, hydrochlorothiazide,irbesartan, metformin, pioglitazone, and warfarin.

ABSTRACT: The cause of edema can usually be determined by judicious use of clues from the history, physical examination, and laboratory results. Localized edema can be the result of deep venous thrombosis, venous stasis, cellulitis, vascular insufficiency, or diuretic abuse; it can also be idiopathic. Clues that are helpful in distinguishing among these conditions include tenderness, positive Homans sign, hair loss on the legs, nonpalpable pulses, and a history of lower extremity injury. Edema of the lower extremities that is accompanied by massive ascites is typical of cirrhosis. Edema of the lower extremities unaccompanied by ascites can be associated with inferior vena cava or iliac venous thrombosis or with vasodilator therapy. Generalized edema can result from congestive heart failure (strong clues are dyspnea on exertion and paroxysmal nocturnal dyspnea), renal disease (a common clue is edema of the face and eyes), or preeclampsia. The basic studies to order in patients with generalized edema are a urinalysis, complete blood cell count, serum chemistry panel with total protein and albumin levels, and a 24-hour urine collection, which is especially helpful in distinguishing among the various types of renal disease.

ABSTRACT: Restriction of fluid and salt intake is essential in patients with edema. Bed rest and supportive stockings are also helpful. However, diuretics are usually the mainstay of therapy. The effect of thiazide diuretics is relatively mild; they may be adequate in patients with cirrhosis but are ineffective in those with congestive heart failure (CHF) or nephrotic syndrome. Loop-acting diuretics can induce massive natriuresis and diuresis. Intravenous loop diuretics are preferred to oral agents for the relief of pulmonary edema. Acetazolamide, a carbonic anhydrase inhibitor, is commonly used in patients with glaucoma and is also recommended for those with CHF accompanied by metabolic alkalosis. Combination therapy is recommended for patients with refractory edema and normal or somewhat impaired renal function. The adverse effects of thiazide and loop-acting diuretics include renal insufficiency, hyponatremia, hypochloremia, hypokalemia, hypomagnesemia, metabolic alkalosis, hyperglycemia, and hyperlipidemia. These effects are typically reversed when the dosage is reduced or therapy is discontinued. Potassium sparing diuretics can cause life-threatening hyperkalemia.

A 32-year-old woman presents with weight loss of 6.4 kg (14 lb) during the past 8 months and diarrhea of recentonset. Menstruation had ceased 10 weeks earlier. She appears anxious, with pressured speech. Physical examination detectsbaseline sinus tachycardia, sweaty palms, and a diffusely enlarged thyroid gland. Laboratory tests reveal a thyroid-stimulatinghormone (TSH) level of 0.00 µU/mL (normal, 0.45 to 4.5 µU/mL), a free thyroxine (FT4) level of 4.8 ng/dL (normal,0.61 to 1.76 ng/dL), and a positive thyroid-stimulating immunoglobulin (TSI) level with high titer.

A 48-year-old woman with a historyof hypertension and mildasthma has been transferred to themedical service because of an abnormalpostoperative ECG. She hadbeen admitted 2 weeks earlier to thegynecology-oncology service for localrecurrence of a previously resecteduterine sarcoma and underwent laparotomyfor debulking of the pelvicmass and resection of the rectosigmoidcolon. She did well until postoperativeday 14, when sudden chestpain and dyspnea developed.

Most sport-diving problems are mild and self-limited; however, serious or life-threatening situations can arise. In a previous article (CONSULTANT, June 2004, page 961), we addressed fitness and safety issues. In this article, we review the principal medical problems associated with sport diving.

ABSTRACT: Consider hyperthyroidism in patients who complain of anxiety or nervousness and palpitations. The diagnosis can be confirmed by measurement of thyroid-stimulating hormone, free thyroxine, and free triiodothyronine levels. Graves' disease is the most common cause of hyperthyroidism; more women are affected than men. A radioiodine uptake test and thyroid scan can distinguish among the various causes of hyperthyroidism. Reserve fine-needle aspiration and biopsy for patients with palpable thyroid nodules. Radioiodine ablation is the treatment of choice for most patients. Some patients, such as children, pregnant women, and patients with large goiters, may be candidates for total or partial thyroidectomy. Antithyroid medications-propylthiouracil and methimazole-are appropriate for patients with mild hyperthyroidism, pregnant women, and children and adolescents with Graves' disease.

ABSTRACT: Guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction have been updated following results from pivotal controlled trials. The new American College of Cardiology/American Heart Association guidelines stress risk factor modification and long-term management. Medications that have been shown to reduce the incidence of future cardiovascular events in patients with acute coronary syndromes include antiplatelet agents, statins, ß-blockers, and angiotensin-converting enzyme inhibitors. Other long-term management strategies include smoking cessation, achievement and maintenance of optimal weight, daily exercise, appropriate diet, and control of hypertension and diabetes.

ABSTRACT: Urinary incontinence is a widespread disorder that remains underdiagnosed, underreported, and undertreated. Nevertheless, it is highly treatable. Components of the initial office evaluation include a focused history taking, physical examination, a postvoid residual urine volume measurement, and urinalysis. Behavioral interventions are first-line therapy. These include bladder training, pelvic floor muscle training, biofeedback therapy, and caregiver-dependent interventions. The antispasmodics oxybutynin and tolterodine are the most commonly used agents for urge incontinence. Stress incontinence can be treated with pseudoephedrine or topical vaginal estrogen. Imipramine may be helpful in cases of nocturnal or mixed incontinence. Overflow incontinence caused by an anatomic obstruction may be treated with an α-blocker.

A 72-year-old man with a history of rheumatic heart disease presented with pulmonary congestion and syncope. Results of the cardiac examination suggested mitral stenosis and atrial fibrillation with a controlled ventricular response.

ABSTRACT: Most hypertensive patients require lifestyle modification and multiple-drug therapy to achieve current blood pressure (BP) goals of less than 140/90 mm Hg and less than 130/80 mm Hg for those with diabetes mellitus or renal disease. For patients older than 65 years, the recommended initial antihypertensive is a thiazide diuretic. If a diuretic does not adequately control BP or is contraindicated, base the selection of an antihypertensive medication on comorbid conditions. For example, a ß-blocker may benefit a patient with coronary artery disease, while an angiotensin-converting enzyme inhibitor may help forestall renal disease in a patient with type 2 diabetes mellitus. The adage "start low and go slow" is appropriate to help avoid side effects and ensure compliance; however, most elderly patients eventually require standard dosages of medications to adequately control BP.

ABSTRACT: Because physical findings are an unreliable indicator of deep venous thrombosis (DVT), the diagnosis is based on the presence of clinical risk factors and the results of noninvasive tests, such as duplex ultrasonography and impedance plethysmography. Contrast venography is considered the gold standard for the diagnosis of DVT. Uncomplicated DVT is managed with low molecular weight heparin followed by warfarin. When DVT is complicated (eg, by pregnancy or by evidence of pulmonary embolism), the patient is treated with intravenous heparin; the dosage is adjusted to achieve an activated partial thromboplastin time 3 times control. Chronic venous insufficiency is the most common cause of leg ulcers. Treatment goals include reduction of edema, relief of pain, ulcer healing, and prevention of recurrence. Leg elevation and multilayer elastic compression dressings are the mainstays of therapy. Compression dressings are continued until ulcers heal; graded compression stockings are worn to prevent recurrence. Pentoxifylline, 400 mg 3 times a day, is an effective adjunct to compression bandaging. Large or slow-healing ulcers may require skin grafts.

ABSTRACT: Thrombolysis with intravenous tissue plasminogen activator (tPA), administered within 3 hours of symptom onset, is the only FDA-approved treatment for acute ischemic stroke. Recently, intra-arterial prourokinase was found to improve recanalization and clinical outcome when administered to select patients up to 6 hours after symptom onset. Combination intravenous/intra-arterial thrombolysis can compensate for the delays that are often associated with intra-arterial therapy (products of the paucity of qualified centers and the time required for angiography). Increased risk of hemorrhagic transformation is associated with all routes of thrombolytic administration. However, greater awareness of specific risk factors for hemorrhagic transformation-especially newer CT and MRI criteria-may enable physicians to select patients with an optimal chance of benefiting from thrombolytic therapy, and may also extend the therapeutic window. Despite the higher rate of hemorrhagic transformation, thrombolytic therapy has demonstrated a significant benefit in the treatment of patients with acute stroke.

Every minute, an American woman dies of cardiovascular disease (CVD), the leading cause of death among women in the United States. Each year, more than half a million women die of cardiovascular causes, including 250,000 of coronary heart disease.Despite the prominent reduction in cardiovascular mortality in the United States among men, mortality has not decreased recently among women. Since 1984, CVD has killed more American women than men every year.1,2

ABSTRACT: The auscultatory features of heart murmurs-intensity, frequency, quality, configuration, timing, duration, and radiation-can help identify a variety of cardiac disorders. Systolic ejection murmurs have a crescendo-decrescendo configuration. These include innocent murmurs and those associated with aortic stenosis and hypertrophic cardiomyopathy. Systolic murmurs associated with retrograde flow from a high-pressure chamber to a low-pressure chamber usually have a holosystolic configuration. Examples of holosystolic murmurs include mitral regurgitation, tricuspid regurgitation, and the murmur associated with a ventricular septal defect. Diastolic murmurs include regurgitant murmurs, such as the decrescendo murmur of aortic regurgitation, and filling murmurs, such as the presystolic rumble of mitral stenosis, which is preceded by an opening snap. The murmur associated with patent ductus arteriosus is continuous.

Numerous factors put elderly patients at risk for adverse drug events. On average, they take at least 6 medications a day, which increases the likelihood of drug-drug interactions. In addition, many drugs that are safe and effective in younger patients are inappropriate for older persons because of age-related changes and comorbid conditions that affect absorption, distribution, metabolism, and elimination. First-pass metabolism decreases with age, which may increase systemic absorption of some oral nitrates, ß-blockers, estrogens, and calcium channel blockers. The age-related rise in body fat increases the volume of distribution of lipid-soluble compounds, such as diazepam, and prolongs clearance. About two thirds of elderly persons have impaired kidney function; in these patients, the dosage of renally excreted drugs-such as digoxin-needs to be reduced. Other strategies for avoiding adverse drug events are detailed here.

To distinguish between hypertensive emergencies and urgencies and nonurgent acute blood pressure elevation, evaluate the patient for evidence of target organ damage. Perform a neurologic examination that includes an assessment of mental status; any changes suggest hypertensive encephalopathy. Funduscopy can detect papilledema, hemorrhages, and exudates; an ECG can reveal evidence of cardiac ischemia. Order urinalysis and measure serum creatinine level to evaluate for kidney disease. The possible causes of a hypertensive emergency include essential hypertension; renal parenchymal or renovascular disease; use of various illegal, prescription, or OTC drugs; CNS disorders; preeclampsia or eclampsia; and endocrine disorders. A hypertensive emergency requires immediate blood pressure reduction (although not necessarily to the reference range) with parenteral antibiotics. An urgency is treated with combination oral antihypertensive therapy.

ABSTRACT: The basic screening studies for rheumatic diseases are a complete blood cell count, a determination of the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level, a rheumatoid factor assay, an antinuclear antibody (ANA) test, a measurement of serum uric acid level, and a urinalysis. Test results must be interpreted within a clinical context; for example, a positive ANA assay suggests the possibility of a rheumatic disorder, but it is not specific for any diagnosis. Tests that reveal the nature and extent of target-organ involvement, such as renal function studies in patients with systemic lupus erythematosus, can help guide the selection of therapy. Laboratory results also reflect disease activity; the ESR and CRP level are useful gauges of the activity of most inflammatory rheumatic disorders. Finally, laboratory monitoring can help you minimize the significant toxicity associated with many of the drugs used to manage rheumatic diseases.

Numerous factors contribute to the medication errors that kill up to 98,000 patients each year. Unnecessarily high dosages can result in increased side effects with only a small therapeutic benefit, especially in elderly patients. Lack of patient information-such as a history of allergies or adverse drug reactions-is another cause of error and injury. Communication failures include the use of ambiguous abbreviations, misinterpretation of verbal orders, and lack of timely response to a patient's medication-related symptoms. Dosing errors are common in children because of variability in dosage expressions in drug references. Remedies for prescribing errors are described in detail here.

A methodical approach to diagnosis usually reveals the cause of fever. In patients with simple fever, a careful history taking and physical examination combined with basic laboratory and imaging studies (complete blood cell count with differential, urinalysis, and possibly a chest film and blood cultures) usually yield the diagnosis. In patients with prolonged fever whose cause remains undiagnosed after extensive examination (fever of unknown origin), repeat the history taking and physical examination; also order routine laboratory studies, an HIV test, a tuberculin skin test, 3 sets of blood cultures, and chest films. In addition, abdominal CT scanning is often useful. Further testing at this point may include fluorodeoxyglucose positron emission tomography, technetium-tagged white blood cell scanning, transesophageal echocardiography, liver biopsy, bone marrow examination, and/or temporal artery biopsy. Exploratory laparotomy is rarely indicated.

Q:Which combinations of antihypertensivemedications are most effective-and which arebest avoided?

A 75-year-old obese woman with subacute-onset dyspnea and lower right posterior chest pain was brought to the emergency department. She had a history of diastolic heart failure, arthritis, and suspected obstructive sleep apnea. The patient was dyspneic at rest.

ABSTRACT: Diuretics remain a mainstay of heart failure therapy. Angiotensin-converting enzyme (ACE) inhibitors and ß-blockers inhibit activation of neurohormonal systems; these agents are recommended for most patients with symptomatic systolic heart failure. Angiotensin II receptor blockers (ARBs) are alternatives for patients who are unable to tolerate ACE inhibitors. Recent trials suggest that ARBs are also useful when added to the regimen of patients with a low ejection fraction. Although digoxin can provide long-term inotropic support in men, it significantly increases the risk of mortality in women; because of the risk of toxicity, use digoxin with caution in older persons and patients with renal dysfunction. Consider an aldosterone antagonist in patients who remain symptomatic at rest despite the use of a diuretic, digoxin, an ACE inhibitor or an ARB, and a ß-blocker. Lifestyle modifications such as dietary restriction and exercise are helpful in all patients.

Your patient with type 2 diabetes wants to take a step exercise class. What recommendations will you offer? Another patient has diabetic retinopathy; which exercises are safest for her?

ABSTRACT: In high-risk patients with vascular disease, blockade of the renin- angiotensin system (RAS) can help prevent cardiac remodeling that ultimately results in left ventricular hypertrophy (LVH) and heart failure. Optimal treatment of these patients, who often have diabetes or renal disease, usually involves a combination of agents-1 of which should be a thiazide diuretic-to reduce blood pressure, control the comorbid condition, and prevent end-stage organ damage. The manner in which the RAS is interrupted may be important. For example, although a thiazide diuretic and an angiotensin-converting enzyme (ACE) inhibitor are recommended for hypertensive patients with LVH, an angiotensin II receptor blocker (ARB) in combination with a diuretic was recently found to reduce cardiovascular morbidity and mortality in these patients to a greater degree than a ß-blocker/diuretic. Both ACE inhibitors and ARBs delay the progression of diabetic nephropathy and reduce albuminuria. ARBs were recently shown to reduce progression from microalbuminuria to macroalbuminuria. In patients with systolic heart failure who cannot tolerate ACE inhibitors, an ARB can be used with a ß-blocker.

ABSTRACT: Many patients with presumed mild intermittent asthma have unrecognized persistent symptoms; these can be elicited with specific questioning about coughing, wheezing, shortness of breath, chest tightness, nighttime awakenings, and exercise intolerance. Asthma severity may vary with the season. For asthmatic patients with predictable seasonal allergies, prescribe inhaled corticosteroids for a few weeks or months beginning 2 to 3 weeks before usual symptom onset. Successful long-term management requires identification and control of asthma triggers, such as cigarette smoke, house dust mites, cockroaches, molds, and animal dander. Removing triggers or minimizing the patient's exposure to them may allow improved asthma control with lower dosages of corticosteroids.

Persons with a systolic blood pressure (BP) of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg are now considered, according to the latest Joint National Committee (JNC) report on hypertension.