Cardiology

The morning after an 88-year-old woman with symptomatic second-degree type I (Wenckebach) atrioventricular block underwent placement of a dual chamber pacemaker without complication, she awoke with uncomfortable pulsations in her abdomen. The pacing thresholds and impedance had remained unchanged since implantation.

Systolic hypertension is an independent risk factor for coronary artery disease, stroke, and end-stage renal disease. Nonpharmacological interventions for systolic hypertension include limitation of dietary sodium and alcohol intake along with weight reduction and aerobic exercise.

A 57-year-old woman presents for follow-up several months after a series of thrombotic episodes. Four days after she underwent ankle fusion to relieve pain and edema associated with a leg fracture that had occurred 40 years earlier, she sustained a massive myocardial infarction (MI).

In medicine, for far too long, men and women were lumped together into "one size fits all" algorithms or, worse, women were presumed to be smaller versions of their male counterparts.

An obese 61-year-old man with a history of heroin abuse was brought to the hospital after he had fallen onto his buttocks on a sidewalk. He was able to stand initially, but weakness and numb-ness in his legs rendered him suddenly unable to walk or prevent himself from voiding. He denied abdominal or back pain. His medical history included asthma, chronic obstructive pulmonary disease, and hypertension.

In recognition of Valentine's Day, we present 2 incidental heart-shaped findings we encountered within the hearts of 2 patients during 2-dimensional transthoracic echocardiographic studies.

With patients who say that they usually faint when blood is drawn or when given an injection, have them lie down and tell them that they "cannot faint when lying down." Whether for physiological or psychological reasons, patients usually do not faint when this is done.

To help answer the question of Mary Ellen Lewis, PA-C, about her patient with a low-density lipoprotein (LDL) cholesterol level of 120 mg/dL and a high-density lipoprotein (HDL) cholesterol level of 100 mg/dL(CONSULTANT, June 2007), I would like to describe my approach to the treatment of dyslipidemia.

A 62-year-old man presents with painful cramps in his left lower leg that began about 6 months earlier and have recently become more frequent. The cramps occur with vigorous walking and cease when he stops for several minutes.

Nephropathy develops in about 30% of patients with diabetes. Screen for albuminuria at the time type 2 diabetes is diagnosed and within 5 years of diagnosis of type 1 diabetes.

During the first quarter of a football game, a 17-year-old athlete noticed that his right (dominant) arm was swollen and heavy. Two days earlier, he had fired a shotgun right-handed multiple times while hunting.

An oral renin inhibitor, aliskiren, recently became available. Does it have any advantages over angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)?

When angiotensin-converting enzyme (ACE) inhibitors were first discovered, they were a welcome addition to the antihypertensive armamentarium. Since then, many more benefits of these drugs have been found: they slow the progression of diabetic nephropathy, abate the sequelae of heart failure when systolic dysfunction is present, and reduce the level of proteinuria in patients with nephrotic syndrome.

Despite meticulous titration of anticoagulation therapy and careful attention to confounding medications, serious bleeding complications occur in some patients who receive warfarin.

Some of my patients who are being treated for hypertension, hyperlipidemia, or both claim that an elevated blood pressure reading or lipid level measurement resulted from a sodium- or fat-laden meal that they had eaten 1 or 2 days before their office visit.

At what level should a patient's blood pressure be before he or she has carotid surgery?

Treatment of hypertension can minimize both microvascular and macrovascular complications of diabetes and helps prevent nephropathy and cardiovascular events.

Is there any relationship between hiccups and an implanted cardiac pacemaker? Could hiccups possibly trigger a change in the pacemaker?

Primary care practice is filled with patients who have acute coronary disease complicated by multiple comorbid conditions. In this era of percutaneous treatments, contrast-induced nephropathy persists as an unwelcome and debilitating complication.

A 44-year-old man presents to the emergency department (ED) with light-headedness, nausea, and vomiting of 1 day's duration. He has also had intermittent palpitations but denies chest pain, dyspnea, and weakness.

In his article, "Heart Failure: Part 1, Diagnosis and Staging" (CONSULTANT, July 2007), why did Dr W. H. Wilson Tang omit central venous pressure and circulation time as means of diagnosing congestive heart failure? Is it possible that the simplicity and accuracy of these 2 tests, which can establish the diagnosis in 5 or 10 minutes in any hospital room-or physician's examining room-have been forgotten since the advent of testing of natriuretic peptide levels (which, as Dr Tang notes, "also increase in response to other noncardiac processes")?

The development of more sophisticated testing modalities now permits the identification of coronary artery narrowing in asymptomatic adults. The images obtained in these studies provide potential targets for intervention-based therapy.

For 4 days, a 34-year-old pregnant woman had dyspnea and right-sided chest pain. She denied fever, chills, sweats, cough, lower extremity pain, and edema. Surgical and social histories were unremarkable. She was taking progesterone and clomiphene citrate for the past 6 months for assisted reproduction.

Over the past 20 years, the treatment armamentarium for diabetes has greatly expanded: 8 different classes of non-insulin drugs and 8 different types of insulin are now available. The newer classes of agents include disaccharidase inhibitors, thiazolidinediones, meglitinides, glucagonlike peptide analogs, and dipeptidyl peptidase IV inhibitors.

Forty-eight hours ago, a 39-year-old man presented to the emergency department with emesis and severe upper abdominal pain of semi-acute onset, which radiated slightly to the back.

A 63-year-old man with a history of hypertension and gastroesophageal reflux disease presented with progressive, sharp mid-abdominal pain of 3 weeks' duration.

Interatrial septal aneurysm (IASA) and patent foramen ovale (PFO)-either alone or coexisting-are a frequent cause of cryptogenic cerebral and/or peripheral thromboemboli. The IASA plus PFO combination has been shown to confer higher risk, particularly in adults aged 45 years or younger. Therefore, recognition and documentation of these 2 abnormalities during an echocardiographic (transthoracic or transesophageal) study, when performed for other indications, is essential.

I read with interest Dr Gregory Rutecki's response to a reader's comments (CONSULTANT, February 2007), in which he emphasized the need for early screening and treatment of cardiovascular disease in patients with chronic kidney disease (CKD).

A 68-year-old woman with hypertension complains of intermittent dyspnea and light-headedness. She is asymptomatic during the evaluation. Vital signs are normal, but an irregularly irregular pulse is noted on examination as well as on the telemetry monitor. The 12-lead ECG is shown here; the ECG machine printout reads "atrial fibrillation." The patient has no history of this arrhythmia.

Current evidence suggests that out-of-office blood pressure measurements and 24-hour ambulatory blood pressure monitoring are better predictors of cardiovascular risk than routine office measurements. Is it time to make greater use of automated devices in my practice?