Cardiovascular Disease

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)?

Your middle-aged patientwith type 2 diabetes wishesto start a weight-trainingprogram. What recommendationswill you offerhim? Another diabetic patient hasperipheral neuropathy; which exercisesare safest for her?

A 45-year-old man presents with a 1- to2-week history of low-grade fever and nonproductivecough. He has a long history of cigarette and alcoholabuse. The office nurse expresses her concern about thepatients cyanotic nail beds and requests your immediateevaluation.

An 83-year-old woman is hospitalized for treatment of deep venous thrombosisin her left leg. She underwent left hip replacement surgery 2 months earlier.At that time, mild anemia (hemoglobin level, 10 g/dL) was noted, and iron therapywas initiated. An iron panel obtained shortly after the hip surgery revealeda serum iron level of 80 μg/dL, a transferrin level of 360 mg/dL, and a ferritinlevel of 50 ng/mL.

Lately I have heard that "tissue ACE" properties are important in endothelial remodelingand in the prevention of myocardial infarction and stroke.

My patient-an 84-year-old woman with hypertension-presented with itchingand blistering of 3 days’ duration on her right foot (Figure).

Q:Should hypertensive patients be discouraged from participating inmoderate to vigorous exercise?A:On the contrary, most patients with sustained hypertension should bestrongly encouraged to exercise regularly at moderate to vigorous levels.Randomized controlled clinical trials have demonstrated that increasedphysical activity can lower blood pressure (BP) and delay or prevent the developmentof hypertension and thus the need for antihypertensive medication.1In addition, physical activity can help reduce cardiovascular risk factors by improvinglipid profiles and reducing weight and blood glucose levels. In elderlypersons, exercise is associated with improvements in osteoporosis, depression,and physical functioning, as well as an enhanced sense of well-being.

Cataracts areone of themost importantcauses ofreversibleblindness in elderly persons.1 A recent report thatpredicts a surge in cataractincidence has heightenedawareness of the importanceof proper timing andtechniques for cataract extraction.The study, authoredby the Eye DiseasesPrevalence ResearchGroup, estimated that thenumber of Americans withcataracts will increase byapproximately 50% in thenext 20 years as the populationages.2 Cataracts werethe leading cause of low vision(less than 20/40 bestcorrected visual acuity inthe better-seeing eye)among whites, blacks, andHispanics.

Pediatric ECGs vary by age;tracings change considerablyfrom birth through adulthood.In the ECG tracing above, theT waves are inverted. Nevertheless,as we outline here, the tracingis normal in a 9-year-old child; theT waves may not revert to normaluntil he reaches puberty.

The FDA has approved injectable Acetadote (acetylcysteine)from Cumberland Pharmaceuticals Incto prevent or lessen liver damage resulting from an overdoseof acetaminophen. According to the FDA, unintentionalacetaminophen overdose is responsible for 100deaths and 56,000 emergency department visits per year.

Use this scale to easily rememberdesirable lipid levels:

Is treatment recommended for high-normalblood pressure (BP)-say, 135/88 mm Hg-ina postmenopausal woman?

We chose to present this case to readersbecause the patient’s neurologicexamination was normal and her presentationthus appeared benign.

What should be included in the optimal cardiovascular evaluation of a highschool athlete?

I have read that mental confusion and paranoia may be potential side effects ofcertain angiotensin-converting enzyme (ACE) inhibitors.

A 67-year-old man complainsof abdominal distention and bouts ofdiarrhea with intermittent constipation.These symptoms have beenpresent for weeks but recently havebecome more severe. The patienthas not seen blood in his stool. Hedenies fever, travel to a foreign country,and recent trauma. He has hypertension,which is well controlledwith calcium channel blockers.

For several weeks, a 68-year-old man has had painful blisterson his hands that crusted as they healed. The patienthas diabetes mellitus, hypertension, and chronic renalfailure, for which he is undergoing hemodialysis. His longtermmedications include a hypoglycemic agent and adiuretic.

A 62-year-old woman was found on thefloor of her bathroom at home with herwheelchair partially on top of her.She was unresponsive except to painfulstimulus.

>Editor’s note: To clearly illustrate the difference between arightward shift of axis and right axis deviation, Dr RichardHarrigan, associate professor of emergency medicine atTemple University School of Medicine in Philadelphia anda regular contributor to CONSULTANT’s “ECG Challenge”feature, provided the 3 ECGs shown here.

What is the risk of dementia in patients who have had an ischemic stroke?

A 20-year-old woman has had several episodes of syncope since she enteredcollege 2 months earlier. Although 1 or 2 episodes were associated with exercise,most were not. All occurred at times of surprise and/or emotional stress:she fainted twice when the bell rang at the end of a test, once after her alarmclock suddenly awakened her in the morning, and once when she received adisturbing phone call from home.

A 62-year-old woman presents with severe, sharp pain in her right mid chestthat worsens when she breathes. The pain began the previous night, shortlyafter she had been awakened by a shaking chill, followed by the sensationof fever. She also has a relatively nonproductive cough of recent onset.