Cardiology

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.

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

My patient has diabetes, end-stage renal disease, and congestive heart failure (CHF)--and does not want to use insulin. What oral medication(s) would be considered optimal in this setting?

In patients with diabetes who have end-stage renal disease and CHF, the choice of oral medications is limited because metformin is contraindicated. Glipizide has a 5% renal clearance and is relatively safe. Studies suggest that glimepiride is the safest of the sulfonylureas.

ABSTRACT: Subclinical hypothyroidism is associated with elevated low-density lipoprotein (LDL) cholesterol levels and several factors related to atherosclerosis, including increased C-reactive protein levels and impaired endothelium-dependent vasodilatation. However, considerable controversy exists about screening for and treating this thyroid disorder. Thyroxine therapy lowers elevated LDL cholesterol levels in patients whose serum thyroid-stimulating hormone (TSH) concentrations are higher than 10 mIU/L ; thus, most experts recommend treatment for such patients. However, there is no consensus regarding the management of patients with TSH levels of less than 10 mIU/L. Although the evidence supporting treatment of these patients is not compelling, it is reasonable to offer a therapeutic trial of thyroxine to those who have symptoms.

ABSTRACT: Our knowledge of chronic diseases has advanced significantly in recent decades, but patient outcomes have not kept pace. This is largely because the traditional acute care model does not adequately address the needs of patients with chronic disease. Patients play an active role in the management of chronic disease, and successful outcomes are highly dependent on adherence to treatment. Thus, clinicians need to have skills in coaching and encouraging as well as an awareness of factors in patients' backgrounds that are likely to affect their ability or willingness to follow treatment plans. Provider- and system-related factors, such as lack of reimbursement for counseling and high copayments, can also act as barriers to compliance. Among the strategies that can improve adherence are the use of community resources, multidisciplinary approaches, and regular follow-up.

The recent editorial by David T. Nash, MD, "OTC Statins: Panacea or Pandora's Box?" (CONSULTANT, July 2006, page 845), prompted a number of readers to write in. A selection of the comments received, along with a response from Dr Nash, appears below. Additional comments appear on www.ConsultantLive.com.

Five days after starting aspirin and warfarin with an enoxaparin bridge for new-onset atrial fibrillation, a 92-year-old man presented with abdominal pain, nausea, and vomiting. The patient appeared ill and was tachycardic. He had dry mucous membranes; pale sclerae; diminished bowel sounds; and a large, tender left lower abdominal mass. Hematocrit was 22% (baseline, 39%); hemoglobin, 6.8 g/dL; blood urea nitrogen, 65 mg/dL; and creatinine, 3.2 mg/dL (baseline, 1.3 mg/dL). His "pre-renal" ratio was 20. These findings were consistent with bleeding and acute renal failure. He also had a supratherapeutic international normalized ratio (INR) of 4.1.

A 50-year-old man with alcohol-induced cirrhosis was hospitalized with lower GI bleeding. On examination, he was pale, heart rate was 100 beats per minute, and blood pressure was 100/60 mm Hg. He was anemic (hemoglobin level, 9 g/dL) and thrombocytopenic (platelet count, 112,000/µL).

The term "prehypertension" was introduced in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines to describe blood pressures (BPs) of 120/80 mm Hg to 139/89 mm Hg.1

A 64-year-old woman presents with persistent, progressively worsening chest pain and dyspnea of 1 month's duration. She also reports orthopnea, bilateral leg swelling, and weight gain. She denies any history of similar symptoms.

The optimal approach to subclinical hypothyroidism continues to be debated. Experts disagree over screening for thyroid dysfunction, the threshold TSH level for treatment, and the upper limit of normal of the TSH reference range.

Over the past few decades, the management of chronic disease has assumed a greater role in health care. Diseases such as diabetes, chronic obstructive pulmonary disease, and depression have replaced acute disorders as the leading cause of morbidity, mortality, and health care expenditures.

The recent editorial by David T. Nash, MD, "OTC Statins: Panacea or Pandora's Box?", prompted a number of readers to write in.

Should patients with prehypertension be treated with antihypertensive drugs?

A 64-year-old woman presents with persistent, progressively worsening chest pain and dyspnea of 1 month's duration. She also reports orthopnea, bilateral leg swelling, and weight gain. She denies any history of similar symptoms.

Five days after starting aspirin and warfarin with an enoxaparin bridge for new-onset atrial fibrillation, a 92-year-old man presented with abdominal pain, nausea, and vomiting. The patient appeared ill and was tachycardic. He had dry mucous membranes; pale sclerae; diminished bowel sounds; and a large, tender left lower abdominal mass. Hematocrit was 22% (baseline, 39%); hemoglobin, 6.8 g/dL; blood urea nitrogen, 65 mg/dL; and creatinine, 3.2 mg/dL (baseline, 1.3 mg/dL). His "pre-renal" ratio was 20. These findings were consistent with bleeding and acute renal failure. He also had a supratherapeutic international normalized ratio (INR) of 4.1.

A 50-year-old man with alcohol-induced cirrhosis was hospitalized with lower GI bleeding. On examination, he was pale, heart rate was 100 beats per minute, and blood pressure was 100/60 mm Hg. He was anemic (hemoglobin level, 9 g/dL) and thrombocytopenic (platelet count, 112,000/µL).

An 82-year-old man presents with shoulder pain resulting from a fall the day before. He has had intermittent episodes of light-headedness, chest pain, and "flutterings in the chest" over the past week--including one this morning. Episodes last about 2 hours and resolve spontaneously. He denies any loss of consciousness, weakness, or worsening of symptoms with exertion. He also denies headache, abdominal pain, and other injuries. His medical history includes coronary artery disease (treated with bypass grafting 10 years earlier); prostate cancer; and chronic lymphocytic leukemia, for which he is receiving chemotherapy.

An 82-year-old man presents with shoulder pain resulting from a fall the day before. He has had intermittent episodes of light-headedness, chest pain, and "flutterings in the chest" over the past week--including one this morning.

The sale of simvastatin over-the-counter has been approved in the United Kingdom. Is this a first step in permitting other medications for asymptomatic diseases (such as hypertension) to be available over-the-counter? Dr Nash calls for a national debate on the availability of drugs to consumers.

Plumbing analogies can help asymptomaticpatients comprehend the seriousnessof elevated lipid and bloodpressure levels.

A broken nose can result in a greatdeal of swelling and discomfort-andoften bleeding as well.

I have read that the concurrent use of an NSAID and an angiotensin-convertingenzyme (ACE) inhibitor may impair the antihypertensive effect of the ACEinhibitor. What is the mechanism of this interaction?

My patient is taking a statin for hypercholesterolemia, and his liver enzyme levelsare markedly elevated. How should I proceed?

A 22-year-old woman presents with fever and malaise of1 month’s duration. About 3 weeks earlier she went to theemergency department. Erythromycin was prescribed,and the patient was told to seek medical attention if hercondition did not improve. Since that time, her healthhas worsened, the fever has continued, and she has lostweight. She says she has had painful areas on her handsand feet but no rash.

A 20-year-old college student presents with frequent heart palpitations. Hehas been in excellent health.

A 24-year-old woman complained of a rash on both feet and legs. She had also had intermittent pain in both ankles for the past year.

Diabetes is epidemic! The numbersare truly alarming. In 1997, official datashowed that 16 million people in theUnited States had diabetes. Approximately1 million had type 1 disease,and 10.4 million had type 2 disease; theremainder had undiagnosed diabetes.1If these numbers are projected outagainst an annual increase in diseaseprevalence of about 3.5%, it means thatby the year 2028, 50 million people willhave diabetes. However, the actual rateis closer to 7% each year. As such, approximately100 million Americans-roughly 1 of every 4-will have diabetesby 2028.

A 53-year-old man presents to the emergency department(ED) with chest pain that started the previous night. Thepain began about 30 minutes after he had smoked marijuanaand inhaled cocaine. He describes the pain as tightnessin the left side of the chest that radiates into theneck; he also has a tingling sensation in both the left sideof the neck and the left arm.