Cardiology

During a routine skin examination,periungual erythema and increasedcurvature of the nail plate are notedin a 78-year-old man. The patient hasemphysema and a smoking historyof more than 50 pack-years. Currently,he requires oxygen support forregular daily activity.

In their “Photoclinic” case of a patient with acute pulmonary embolism(CONSULTANT, December 2003, page 1741), Drs Tapas Bandyopadhyay andIsmael Martin state that the patient’s 12-lead ECG (which accompanies the casediscussion) exhibits right axis deviation.

A 24-year-old woman who is 14 weeks pregnant with her first child is heterozygousfor factor V Leiden. The patient is healthy, has no chronic medical conditions,and takes no long-term medications.

A 24-year-old woman complains ofa pruritic rash that erupted after shesoaked in a hot tub a few days earlier.The patient is otherwise healthy;her only medication is an oralcontraceptive.

A 67-year-old woman who is being treated as an inpatient for head traumacomplains of vague tenderness during an abdominal examination. Othercomplaints are difficult to assess. She had been placed on an oxygen ventilator;however, her cognitive function and pulmonary function are improving, andher cerebral edema is diminished.

A vigorous 61-year-old man presents for a preemployment physical examination.He has no symptoms of angina pectoris or congestive heart failure (CHF).

A 22-year-old man presents to theemergency department with a2-week history of a worsening nonproductive,irritating dry cough andexertional dyspnea. The patient hasbeen otherwise healthy. He deniesfever, rigors, night sweats, hemoptysis,chest pain, palpitations, orthopnea,paroxysmal nocturnal dyspnea,ankle edema, and lymphadenopathy.

For 3 days, a 42-year-old man has had episodic dullchest pain. The anterior precordial and retrosternalpain intensifies with inspiration and movement. He has nohistory of recent viral infection, hypertension, coronaryartery disease, cardiac surgery, diabetes mellitus, or hyperlipidemia.There is no family history of cardiovasculardisease.

A 76-year-old woman presents with chest pain-which she describes as“muscle tightness”- that began when she awoke in the morning. Thepain is constant, exacerbated by deep inspiration, and accompanied by asubjective sense of slight dyspnea; she rates its severity as 3 on a scale of1 to 10. She denies pain radiation, nausea, diaphoresis, palpitations, andlight-headedness. Her only cardiac risk factors are hypertension and a distanthistory of smoking.

In their article, “Hypertensive Emergencies and Urgencies: Update on Management”(CONSULTANT, March 2004, page 341), Drs Iris Reyes and Rex Mathewwrite that labetalol is specifically indicated for most hypertensive emergencies,“especially stroke and acute cocaine intoxication.” In fact, labetalol is potentiallydeadly and is contraindicated in acute hypertension and/or concomitant chestpain related to cocaine intoxication.

A30-year-old man complains of chest pain, dyspnea, fever, and nonproductivecough that began earlier in the day. The pain is constant and does notdiminish with rest; it worsens somewhat with deep inspiration and has localizedto the left chest. The patient has had no nausea, vomiting, or abdominal pain.He has been immobile for several years secondary to spinal cord disease buthas no history of cardiopulmonary disease.

A variety of clinical syndromes can cause T-wave inversions; these range from life-threatening events, such as acute coronary ischemia, pulmonary embolism, and CNS injury, to entirely benign conditions. Here: a discussion of conditions that can cause T-wave inversions in leads V1 through V4.

BOSTON -- Multiple biomarkers such as C-reactive protein, homocysteine, and B-type natriuretic peptide add nuance but little substance to time-honored prognostic cardiovascular risk factors, researchers here reported.

CHAPEL HILL, N.C. -- Low levels of LDL cholesterol appear to confer a greater risk of Parkinson's disease, suggesting that it's possible to have too little of a bad thing, researchers here reported.

Despite Pfizer's high-profile drug failure, boosting HDL still a key heart-disease strategy. Several drugs in development use various mechanisms to raise levels of "good cholesterol." Meanwhile, physicians can do plenty right now to raise patients' HDL levels.

A 73-year-old woman presents with apainless, nonpruritic rash of recent onseton her right lower ankle. She has nofever, chills, nausea, vomiting, malaise,or other systemic complaints. Her medicalhistory includes fibromyalgia, osteoarthritis,stable angina, and anxiety;there is no history of connective tissuedisease.

I enjoyed Dr Henry Schneiderman’s “What’s Your Diagnosis?” case of an elderly woman with severe facial ecchymoses from a fall. Would Dr Schneiderman elaborate on several points about that case? This woman did not trip or complain of dizziness before she fell. What caused her to fall?

Excessive sweating, or hyperhidrosis, can be primary or secondary. Cardiac disease can cause hyperhidrosis. If the results of his laboratory workup are normal and he does not show evidence of leukemia, lymphoma, infection, or diabetes, then I would try treating him for primary hyperhidrosis.

Amiodarone, a class III antiarrhythmic, has become the drug of choice for the management of supraventricular and ventricular arrhythmias.1,2 Although not an FDA- approved indication, the use of amiodarone to treat atrial fibrillation is supported by practice guidelines from the American College of Cardiology/ American Heart Association (AHA) and the European Society of Cardiology.

A 49-year-old man presents with recurring facial pain of 6 months' duration. The pain initially occurred several times per week; it now occurs as often as several times per day. The paroxysmal pain is intense and incapacitating but abates within several minutes. It occurs in the right maxillary region and lower jaw and is sharp and lancinating. Hard chewing and teeth cleaning are the usual precipitating events. Between episodes, the patient is asymptomatic, without numbness or deficit in the affected region.

A 26-year-old otherwise healthy man presents to the emergency department with a 3- to 4-hour history of left-sided chest pain. The pain is pleuritic and accompanied by nausea and discomfort in the left arm.

A 26-year-old woman with dull left-sided chest pain, nausea, body aches, and low-grade fever is admitted to the hospital. She has been to other emergency departments (EDs) in the area recently with similar complaints and was sent home with diagnoses of anxiety and costochondritis.

When your patient presents with chest pain and other symptoms of an acute coronary syndrome (ACS), yet a standard 12-lead ECG shows no evidence of ST-segment elevation myocardial infarction (STEMI), you may face a diagnostic dilemma. The patient could have a non-STEMI ACS for which conservative treatment will suffice--or he could have a STEMI in an electrocardiographically "silent" area and need acute reperfusion therapy.

A 26-year-old woman with dull left-sided chest pain, nausea, body aches, and low-grade fever is admitted to the hospital. She has been to other emergency departments (EDs) in the area recently with similar complaints and was sent home with diagnoses of anxiety and costochondritis.

When your patient presents with chest pain and other symptoms of an acute coronary syndrome (ACS), yet a standard 12-lead ECG shows no evidence of ST-segment elevation myocardial infarction (STEMI), you may face a diagnostic dilemma.

Approximately 90% of cases of lung cancer are attributable to smoking-either directly or as a result of passive exposure. Fifty percent of smokersdie of a smoking-related disease. The 4 most common causes of death-heartattack, lung cancer, chronic obstructive pulmonary disease, and stroke-areall associated with smoking. More lung cancer is diagnosed in former than incurrent smokers.1 The risk of lung cancer decreases each year following smokingcessation, but former heavy smokers will always have a higher risk thannonsmokers.

The authors report the incidental finding of a persistent left superior vena cava (PLSVC) during the routine placement of a left subclavian central line in an elderly man with acute renal failure.

A 29-year-old man presents with a recent episode of light-headedness of sudden onset. Although he denies associated loss of consciousness, witnesses report that he was briefly unresponsive to verbal stimuli. He also denies chest pain, dyspnea, palpitations, and diaphoresis; he is currently asymptomatic.

Q: What is the lowest acceptable diastolic blood pressure (DBP) in a patient with systolic hypertension who is older than 65 years?

A 29-year-old man presents with a recent episode of light-headedness of sudden onset. Although he denies associated loss of consciousness, witnesses report that he was briefly unresponsive to verbal stimuli. He also denies chest pain, dyspnea, palpitations, and diaphoresis; he is currently asymptomatic.