Cardiology

A 57-year-old man requests an extensive medical evaluation as part of a transition in the ownership of his business. He is generally healthy, although he reports that his capacity for physical exertion has diminished over the past several years. He denies chest pain with effort, dyspnea at night or on exertion, cough, and sputum production.

ABSTRACT: Patients who experience an acute myocardial infarction (MI) are at very high risk for recurrent cardiovascular events. Both site-supervised and home-based cardiac rehabilitation programs can effectively reduce all-cause and cardiovascular mortality. Start risk factor reduction as soon as possible; pharmacotherapy is best initiated while patients are still in the hospital. All patients who have had an MI should receive aspirin, an angiotensin-converting enzyme inhibitor, and a ß-blocker, unless these agents are contraindicated or are not tolerated. Prescribe aggressive lipid-lowering therapy to bring patients' low-density lipoprotein cholesterol levels to below 70 mg/dL. For smokers, quitting is the single most important change they can make to reduce future risk of MI.

What is "normal" blood pressure (BP)? Is it different from optimal BP?

For several months, a 52-year-old woman has had burning discomfort in the region of her lower sternum and frequent acid/sour sensations in her throat; the symptoms are usually associated with burping after meals and recumbency.

A 24-year-old woman presents to the emergency department (ED) withgeneralized weakness, headache, and muscle cramping that have progressivelyworsened over the past week. Recently, she has also had nauseaand vomiting. She denies chest pain, palpitations, dyspnea, cough, fever,chills, diarrhea, and urinary symptoms. She has a history of type 1 renaltubular acidosis.

A 60-year-old man was hospitalized with fever and hypotension secondary to recurrent cellulitis of the left leg. He had a history of polysubstance abuse and hepatitis C. Elephantiasis nostras verrucosa was diagnosed based on bilateral nonpitting edema and hyperkeratotic verrucous lesions in the pretibial area. The patient's erythrocyte sedimentation rate and white blood cell count showed evidence of infection; osteomyelitis of the left fifth metatarsal head was suspected.

A 57-year-old woman presents with swelling of the hands that began several weeks earlier and is now worsening. She denies joint pain, and she has no history of trauma or significant vascular disease. She has had pneumonia several times; each episode was successfully treated with antibiotics. She has smoked 2 packs of cigarettes a day for the past 20 years

The goal of treatment in acute coronary syndromes is the restoration and maintenance of myocardial perfusion. To this end, numerous pharmacological agents are available, as well as percutaneous coronary intervention (PCI).

Numerous randomized trials have evaluated antihypertensive regimens in various settings, including those complicated by at least one other vascular disorder. Among these trials are the Modification of Diet in Renal Disease (MDRD) Study in hypertensive patients with kidney disease; the Comparison of AMlodipine versus Enalapril to Limit Occurrences of Thrombosis (CAMELOT) Study and the INternational VErapamil-trandolapril STudy (INVEST) in patients with hypertension and coronary disease; and the Perindopril pROtection aGainst REcurrence of Stroke Study (PROGRESS) in hypertensive patients who have had a stroke.

Although the definition of orthostatic hypotension requires that the significant drop in blood pressure observed on standing be sustained for 3 minutes (which provides evidence of true autonomic failure), clinicians who use this as a diagnostic criterion may be doing many patients a disservice. Most people who fall as a result of a drop in blood pressure do so on arising, as they get up from a bed or chair. Moreover, many hip fractures caused by falls occur in patients who experience a drop in blood pressure on standing. If patients can stand for 3 minutes without wavering or falling, their body is accommodating well.

In imaging studies in patients older than 55 yearswith suspected coronary artery disease or peripheralvascular disease, more than 80% of renal artery lesionsare associated with generalized atherosclerosis.

ABSTRACT: Antiplatelet agents used to treat non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina include aspirin, clopidogrel, and glycoprotein (GP) IIb/IIIa inhibitors. Aspirin is recommended for all patients with acute coronary syndromes (ACS). Clopidogrel can also be used in all patients with ACS, although this agent increases the risk of major bleeding complications if coronary artery bypass grafting is performed less than 5 days after the last dose. Early use of a GP IIb/IIIa inhibitor provides additional benefit in patients with NSTEMI, particularly those who undergo percutaneous coronary intervention. Agents used for anticoagulation in patients with NSTEMI or unstable angina include unfractionated heparin, low molecular weight heparins (LMWHs), and the direct thrombin inhibitor bivalirudin. Enoxaparin-the only LMWH currently indicated for treatment of patients with NSTEMI-can be considered as an alternative to unfractionated heparin, particularly in those who do not require urgent cardiac catheterization.

ABSTRACT: A 4-pronged approach that includes patient education, skin and nail care, appropriate footwear, and proactive surgeries can effectively prevent diabetic foot problems. Teach patients with diabetes to examine their feet daily to detect new onset of redness, swelling, breaks in the integrity of the skin, blisters, calluses, and macerated areas. Have them follow a daily foot care regimen that includes warm water soaks and lubrication, and have them keep toenails properly trimmed. Recommend that patients select shoes that fit properly and have sufficient padding and toe box space; have them use inserts, lifts, orthoses, or braces--as recommended-to correct abnormal gait patterns. Finally, if deformities develop, simple proactive surgical procedures can correct these problems before they result in the development of wounds.

abstract: In the past, constrictive pericarditis was most often caused by tuberculosis. Today, however, it is more likely to be preceded by injury or trauma, infection, or previous cardiac surgery. Most patients with constrictive pericarditis present with dyspnea and have elevated jugular venous pressure. Other potential symptoms and signs include peripheral edema, abdominal fullness, hepatomegaly, ascites, and chest pain. Electrocardiography demonstrates nonspecific ST-segment and T-wave changes and generalized T-wave inversion or flattening. In many cases, chest radiography and CT reveal pericardial calcification, and echocardiography shows increased pericardial thickness and calcification. Treatment may include NSAIDs, corticosteroids, antibiotics, angiotensin-converting enzyme inhibitors, and diuretics. Surgery is the treatment of choice for chronic disease, and pericardiectomy is typically effective. (J Respir Dis. 2007;28(2):49-56)

ABSTRACT: Angiotensin-converting enzyme (ACE) inhibitor therapy is recommended for all patients with heart failure (HF) and a reduced ejection fraction. It is generally initiated in the hospital at low doses as inotropic therapy is tapered. Angiotensin II receptor blockers may be a suitable alternative for patients who cannot tolerate ACE inhibitors. For patients who cannot tolerate either class of drug, a combination of hydralazine and a nitrate is recommended. ß-Blockers are first-line therapy for patients with current or previous symptoms of HF and reduced left ventricular function, as well as all patients hospitalized for HF. An aldosterone antagonist may be added to the regimen of patients with moderately severe to severe symptoms and reduced ejection fraction whose renal function and potassium concentration can be monitored.

In his recent editorial Putting Guidelines for Chronic Kidney Disease IntoPractice (CONSULTANT, October 2006, page 1295), Dr Gregory Ruteckidiscussed the results of a study that shows many clinicians fail to follow evidence-based guidelines for the management of chronic kidney disease(CKD), such as when to consult a nephrologist.1 A sampling of the feedbackwe received appears below, along with Dr Rutecki's responses.

For a week, a 39-year-old woman with a history of intravenous heroin use had generalized pain, fever, chills, and a nonproductive cough. She rated the pain at 10 on a scale of 1 to 10; it was sharp, constant, and unrelieved by heroin. She also reported dyspnea at rest, pleuritic chest pain, and a 15-lb weight loss over the past month. She had no significant medical history or drug allergies, smoked a half pack of cigarettes per day, and denied alcohol use.

Encourage patients with cardiovascular risk factors who are not allergic to aspirin to carry several "baby" aspirin (81 mg) with them.

To facilitate the assessment of jugular venous pressure, shine a beam of light tangentially across the skin overlying the jugular vein while the patient's neck muscles are relaxed.

In cases of PEA, a rapid, narrow-QRS-complex rhythm is associated with an improved chance of survival.

An 80-year-old woman has a 3-month history of increasing dysphagia (withboth solids and liquids), fatigue, and dyspnea on exertion. She has also involuntarilylost 50 lb during the same period. She reports no abdominal pain orchange in bowel function.

An agitated and confused 51-year-old man is brought to the emergency departmentby his family and friends. Recently, he had been drinking heavilyand smoking cocaine. He stopped using alcohol and cocaine 2 days earlier,after he began to vomit.

Q:Is periodic laboratory monitoring recommended for patients withosteoarthritis who are receiving long-term cyclooxygenase-2 (COX-2)inhibitor therapy and who have no GI or renal symptoms? Similarly,is laboratory monitoring recommended for women who take a selectiveCOX-2 inhibitor to alleviate menstrual cramps (eg, rofecoxib, 50 mg/d,3 to 5 days per month)?--Sarita Salzberg, MDColumbus, Ohio

For 3 months, a 66-year-old retired man has had increasingweakness of the lower legs with stiffness,tingling, and numbness; worsening ataxia; anergia; andexertional dyspnea of insidious onset. He has lost 8 lb,and his appetite is poor. He denies fever, cough, chest orabdominal pain, paroxysmal nocturnal dyspnea, orthopnea,ankle swelling, bleeding disorders, hematemesis,melena, headache, vision problems, sciatica, joint pain,bladder or bowel dysfunction, and GI symptoms. He hasnocturia attributable to benign prostatic hypertrophy.

A 78-year-old widower with hypertension, type 2 diabetes, and hyperlipidemiais referred for a comprehensive geriatric assessment.His daughter is concerned about her father’s decline following her mother’s death a year ago.His memory seems to be deteriorating. His desk is cluttered with bills, but he refuses to lethis daughter help him or even look at his checkbook.

For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.

Q:How can I accurately determine when a patient’s hypertension isresistant to treatment-and what is the best approach to theevaluation?

When the QT interval is prolonged, amultifocal ventricular tachycardiasyndrome (torsades de pointes) mayoccur and produce sudden cardiacdeath. QT prolongation can resultfrom congenital abnormalities, suchas the long QT interval syndrome, orfrom certain drugs. Other factors thatincrease the risk of a prolonged QTinterval and torsades de pointes includehypokalemia, hypomagnesemia,older age, female sex, low ventricularejection fraction, ischemia,and low heart rate.

Q:Under what circumstances is 24-hour ambulatoryblood pressure monitoring (ABPM) appropriate?

Q:Do evidence-based data support combination therapy with anangiotensin-converting enzyme (ACE) inhibitor and an angiotensin IIreceptor blocker (ARB)?