Cardiology

Is heparin necessary for a hospitalizedpatient with an acute coronary syndromeif he or she is receiving long-termwarfarin therapy?

Rapid, accurate diagnosisof acute myocardialinfarction(MI) in patientswith chest pain isa formidable challenge.

A 9-year-old boy fell on his left arm while skating and injured his elbow. Heexperienced no loss of consciousness or associated injury.

For more than 30 years, serumdigoxin concentrations (SDCs)have been monitored toensure safe, effective therapy.1,2Although the therapeuticrange for SDCs is often listed as either0.8 to 2.0 ng/mL or 0.5 to 2.0ng/mL, the results of clinical trials inthe 1990s suggest an upper limit of1.0 ng/mL for treatment of heart failure.3-11 An upper limit for the SDC of1.0 ng/mL is also recommendedfor patients who have heart failureand atrial fibrillation with rapid ventricularresponse.

A 75-year-old man with a 120-pack-year smoking history has dyspnea on exertion(eg, when he walks more than 3 blocks or climbs 1 flight of stairs) butnot when he is at rest or asleep. His symptoms have progressively worsenedover the past 3 to 4 years and have been accompanied by a 20-lb weight loss.

A 40-year-old womancomplains of severe pain in her rightmiddle finger. The discomfort beganseveral weeks earlier, after she sustainedminor trauma to the finger. Anantibiotic was prescribed, but the discolorationand coolness in her fingerspersisted. She denies any recent orchronic illness and says she is a lightsmoker.

For 2 days, a 35-year-old woman has had a tender eruption on the right palm.She takes no medications. The patient recalls that 1 or 2 years earlier a similarrash cleared following a course of antibiotics.

A 67-year-old woman has had an ulcer on her left heel for at least several weeks.She applied a homemade dressing and cut her shoes to try to relieve pressureon the ulcer; however, in the past week, areas around the ulcer have becomepainful. These areas, as well as the dorsum of the foot, are red and swollen.

A 72-year-old man complains that he has been losing weightfor the last 2 months. Colon cancer was diagnosed 2 yearsearlier, and the lesion was resected; he did not receive anyadditional therapy at that time. Except for hypertension,which is well controlled with propranolol, the remainder ofthe medical history is unremarkable.

Over the past 6 months, a 76-year-old African American woman has had increasingdifficulty in swallowing solid food and has lost 40 lb. She can now tolerateonly liquids and foods with a pudding-like consistency. Ingestion of moresolid food produces the sensation that it is “sticking in her chest,” and shesubsequently regurgitates it undigested. She denies heartburn, reflux, nausea,hematemesis, abdominal pain, and melena.

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.

On her eighth day in the hospital for acute pulmonaryembolism, an 88-year-old woman complains of nauseaand abdominal pain and fullness of 12 hours’ duration.The pain is localized to the mid epigastric area and radiatesinto the right lower quadrant. The patient deniesvomiting, melena, and dysuria; she has refused to eat allday.

Q:Based on the latest evidence, what constitutesoptimal management and follow-up for patientswith asymptomatic carotid stenosis?

A 75-year-old woman complains of chest pain that radiates to her back betweenher shoulder blades. The pain began the morning of her presentationand has progressed throughout the day. She denies recent trauma, shortnessof breath, and fever. She has hypertension, which is treated with a &#946-blocker.Three years earlier, she fractured her right femur in a motor vehicle accident;the fracture was treated by open reduction and internal fixation.

For several weeks, a 29-year-old woman has had worsening left lower backpain that is aggravated by sitting and walking. The pain is most severe aboveher left buttock; it radiates into the buttock and very slightly into the leg. Overthe-counter analgesics have been ineffective. Assuming a supine position providessome relief, but the pain still occasionally awakens her at night. She deniesweakness, other neurologic symptoms, and any symptoms of bowel orbladder dysfunction.

Q:Should we be prescribing α-blockers to control hypertension in lightof the ALLHAT findings of adverse effects?

In the recently published Seventh Report of the Joint NationalCommittee on Prevention, Detection, Evaluation, and Treatment ofHigh Blood Pressure (JNC 7), a new category, called "prehypertension,"was added in the classification of blood pressure (BP). What was therationale for this addition?

An 87-year-old man had recently been hospitalized for5 days for treatment of hypernatremia and dehydration.His condition improved following hydration and cautiouscorrection of the hypernatremia, and he was discharged.However, within 48 hours the patient's caregiver notedthat he was obtunded and less responsive; she broughthim to the emergency department.

A 23-year-old woman has had 2 episodesof syncope during the past month.Her mother witnessed 1 episode inwhich the patient collapsed and lostconsciousness for a few minutes. Sheexperienced tonic-clonic seizure activitybut no subsequent confusion.

An 84-year-old man with back and abdominal pain ofrecent onset arrives at the emergency department(ED) of a small community hospital at 5 AM. Sudden,severe back pain awakened him from sleep 2 hours earlier.The patient has had back pain for 12 hours and intermittentcolicky pain in the suprapubic region for the past2 hours.

A 45-year-old woman is admitted for evaluation of intermittentmidsternal chest pain that began 48 hours earlier.The pain is intense and radiates down both arms to theelbows; it has been accompanied by several episodes ofnausea and diaphoresis. She denies classic angina pectorisbut reports that she has experienced episodes of chestdiscomfort that is similar to her current pain-but muchless severe and without radiation-for about 3 months.She has no history of dyspnea on exertion, orthopnea, orparoxysmal nocturnal dyspnea.

A 52-year-old man presented to theemergency department (ED) with a12-hour history of cramping abdominalpain, nausea, vomiting, andwatery, brown diarrhea. Mid upperquadrantpain had begun suddenlythe night before, 1 hour after the patienthad lifted heavy bags of rocks.The GI symptoms persisted with varyingintensity throughout the night.

If you are a long-time reader of this journal, you may rememberthe photographs of authors that once gracedthe cover of every issue of Consultant. The May 1979issue of Consultant featured the picture of Donald Vidtyou see here; for that issue, Dr Vidt wrote “FiveMajor Vasodilators: How They Work” and advised readersabout the cardiovascular and renal hemodynamics ofhydralazine, prazosin, diazoxide, nitroprusside, and (atthat time the investigational agent) minoxidil. A quarter of a century later,Dr Vidt is still writing on the treatment of hypertension for readers of thisjournal-and it is with real pleasure that we introduce him here as a memberof our editorial board.

A 12-year-old black girl is hospitalized because of increasinglysevere dyspnea and sore throat. The sorethroat started about a week earlier and was accompaniedby fever and chills. The patient was evaluated at an urgentcare center when her symptoms worsened, where she wasgiven ampicillin for a presumptive “strep throat.” A generalizedmaculopapular erythematous rash developed within24 hours of the start of therapy, and the ampicillin waspromptly withdrawn. The rash cleared gradually thereafter.Now the patient’s sore throat has worsened to the pointthat she has difficulty with drinking and eating. She hasbecome increasingly dyspneic during the past 24 hours.

A 57-year-old African American man comes to your office because he isconcerned about his blood pressure (BP). When it was measured at a healthfair a month earlier, it was 157/96 mm Hg; a week later at a clinic it was162/97 mm Hg. Now his resting BP is 166/101 mm Hg.

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).

Over the past 8 years, fragile vesicles,painful ruptured bullae, and erosionshave developed on the sun-exposed skinof a 57-year-old man. Some of the vesicleserupt at sites of minor trauma; othersarise spontaneously. A corticosteroidcream prescribed by another practitionerfor presumed atopic dermatitisfailed to clear the lesions.

A 32-year-old woman complains of dyspnea on exertion that has worsenedover the past 6 to 12 months. The condition makes it difficult for her to climbthe 2 flights of stairs to her apartment when carrying packages, is worse oncold days and, on several occasions recently, has been accompanied by dizziness.She denies cough, sputum production, hemoptysis, and chest pain.

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.