How I Healed my Cardiovascular Disease

The Big Heart Disease Lie

The Big Heart Disease Lie is a book written by doctors who are members of the International Truth In Medicine Council they are also the authors of The Big Diabetes Lie. In this book you will be getting over 500 pages of scientifically proven, doctor verified information that you will not find anywhere else, not even bookstores.If you have high blood pressure or cholesterol, fatigue, shortness of breath, irregular heartbeat, swollen feet or ankles, chest pain, fainting, diabetes, asthma or allergies, pain, fatigue, inflammation, any troubling health issue, or simply want to discover the most powerful health and anti-aging program, then you really need to read this book. The book is a step by step guide that contains techniques scientifically verified and proven by doctors to reverse the symptoms of heart disease, and normalize blood pressure and cholesterol levels. These techniques have been used successfully by tens of thousands of people all over the world, and allowed them to take health into their own hands, ending the need for drugs, hospitals, doctors' visits, expensive supplements or grueling workouts. More here...

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Coronary Heart Disease in Vegetarian South Asians

South Asian migrants from the Indian subcontinent (Bangladesh, India, and Pakistan) have higher mortality from CHD than other ethnic groups living in the new host country.84 Reliable population-based CHD mortality data are not available from South Asia, but mortality is probably low in rural areas and high in urban areas.84 Many South Asians are vegetarians, which might suggest that this type of vegetarian diet does not reduce the risk for CHD. However, South Asians differ from other ethnic groups, both in many aspects of lifestyle and also genetically, and a case-control study of risk factors for CHD (specifically acute myocardial infarction) in Bangalore, India, did observe a 45 reduction in risk in vegetarians, which was partly explained by their lower blood glucose concentration and lower waist to hip ratio.85

Transient Ischemic Attack

A transient ischemic attack (TIA) has the same definition as stroke but it lasts for less than 24 hours. The 24-hour threshold is somewhat arbitrary, as up to 28 of TIA patients have an infarct on computed tomography (CT) scan, of which 36 are bilateral. In the U.S., the prevalence of TIA in men aged 65 to 69 years is 2.7 , increasing to 3.6 for men aged 75 to 79 years. The respective prevalence figures for women are 1.6 and 4.1 . In the U.K., the overall incidence of TIA is 0.4 in 1000, but this varies with age. The incidence is 0.25 in 1000 for those aged 45 to 54 years, increasing to 1.61 in 1000 in the 65-to 74-year age group and 2.57 in 1000 in those aged 75 to 84 years.

Cardiovascular Risk Factors

Patients with PCOS may have abnormal lipid profiles, including elevated triglyceride, LDL cholesterol, VLDL cholesterol, and decreased HDL. In a study of more than 200 patients with PCOS, Talbott et al. found increased BMI, insulin, triglyceride, cholesterol, LDL, and blood pressure (72). The elevated insulin levels were found to correlate with the increased cardiovascular risk independently in PCOS patients. The metabolic profile noted in women with PCOS is similar to insulin resistance syndrome, a clustering within an individual of hyperinsulinemia, mild glucose intolerance, dyslipidemia, and hypertension (73). There is a prolific literature identifying obesity, dyslipidemia, glucose intolerance, diabetes, and occasionally hypertension as risk factors for cardiovascular disease in women with PCOS (74-79). However, there is actually little published evidence supporting a link between PCOS and cardiovascular events i.e., increased mortality from CVD, premature mortality from CVD, or...

Coronary Artery Disease

Type 2 diabetes, by virtue of its predisposition to generalized arteriosclerotic vascular disease, inflammatory milieu, and thrombogenesis is truly a vasculopathic state. Ischemic events are the hallmark of morbidity in the diabetic patient, with cardiovascular disease being the primary cause of demise in close to 55 of patients with type 2 diabetes. The risk of sustaining an myocardial infarction in a diabetic patient is the same as the risk of a second myocardial infarction in a nondiabetic patient, and a second myocardial infarction in diabetic patients is almost twice as likely as in nondiabetic patients. Over the past 10 years, the number of hospitalizations as a result of cardiovascular disease has increased by 37 . Therefore, it is not surprising that all patients with diabetes should be treated as if they had existing coronary disease and that coronary disease has been elevated to the top priority for risk reduction. A study by Haftner in the New England Journal of Medicine...

Tocotrienols In Ischemic Heart Disease

Ischemia is a stage when there is no blood flow in a cell as blood is the only carrier of air or oxygen, cells become subject to a lot of stress due to lack of oxygen. When this kind of situation arises in the heart, the disease is known as ischemia heart disease. Apart from atherosclerotic plaque deposition, oxidative stress is also considered as one of the major causes of ischemic heart disease. The excellent free radical scavenging property of tocotrienols attenuates the oxidative stress better compared to tocopherols. That is why, recently researchers are considering tocotrienols as a better therapeutic option from ischemic heart disease compared to tocopherols.

Confusion of LAH with Inferior Wall Myocardial Infarction

You will later learn that one of the hallmarks of AMI is the development of Q waves. In inferior wall myocardial infarction, very deep Q waves can develop in the leads that look at the inferior wall of the heart, that is, in leads II, III, and aVF (Figure 6.6). Figure 6.6. Old inferior wall myocardial infarction with Q waves in leads II, III, and aVF, and with an axis of approximately -5 degrees. Figure 6.6. Old inferior wall myocardial infarction with Q waves in leads II, III, and aVF, and with an axis of approximately -5 degrees. Confusion of LAH with Inferior Wall Myocardial Infarction 39 Figure 6.7. Left anterior hemiblock with deep S waves in the inferior wall (II, III, and aVF) which can be mistaken for old inferior myocardial infarction if the reader does not notice that there are actually tiny initial R waves present inleads III and aVF, and not Q waves. In addition, the LAD is more extreme, at about -50 degrees. Figure 6.7. Left anterior hemiblock with deep S waves in the...

Coronary heart disease

This condition is responsible for the majority of cardiovascular deaths. Although incidence is decreasing, CHD remains the leading cause of death in men and women in developed countries. It thus dominates statistics for cardiovascular mortality and has an impact on total mortality. A number of CHD risk factors have been uncovered by epidemiological studies. Among the established risk factors with probable causal effect are cigarette smoking, HTN, diabetes mellitus, increased LDL cholesterol, and decreased HDL cholesterol. Atherosclerotic narrowing of major epicardial coronary arteries is the usual basis of CHD. Thrombosis in narrowed vessels plays a critical role in major events, such as acute myocardial infarction or sudden death. The biological state of the atherosclerotic plaque and the endothelial lining of the coronary vessels plays an important role in the risk of these major CHD events. These have consistently shown a reduced risk of acute myocardial infarction and death from...

Syndromes of Ischemic Heart Disease

Zones Infarct

The continuum of ischemic heart disease stretches from silent ischemia through the various patterns of angina, AMI, and scars of a previous myocardial infarction, to the complications of AMI, such as ventricular aneurysm or pericarditis. Although all of these syndromes represent a continuum of the same disease process, they may present with quite different ECG patterns at different stages of the continuum, and have distinctly different treatments and outcomes. When a patient presents with chest pain, the ECG can help us to determine where they fit on the continuum. Similarly, the nature of the patient's symptoms and the physical examination can also provide clues as to where the patients fit on the continuum, and can lead us to search for subtle ECG changes that we might otherwise overlook without a high index of suspicion. Stable exertional angina, occurring predictably with a given level of exercise, is the most common initial presentation of ischemic heart disease. Discomfort...

Investigation of Ischemic Stroke

All patients should undergo simple baseline investigations (full blood count, urea electrolytes, glucose, lipids, chest x-ray, electrocardiogram). This not only enables diagnosis of unexpected coexistent pathologies (sickle cell disease, thrombocytosis, etc.), but also enables important risk factors to be corrected (hypertension, diabetes, ischemic heart disease, etc.). There is no need for more complex investigations to be performed routinely (autoantibod-ies, echocardiograms, thrombophilia screens). These should only be undertaken if the history or initial investigations suggest it is appropriate.

Cardiovascular Risk Factors and Peripheral Arterial Disease

A 62-year-old man with intermittent claudication was referred for vascular risk factor modification. He had no history of myocardial infarction (MI) or stroke. He was smoking 20 cigarettes day. His family history was negative for premature vascular events. He was not taking any medication. He was advised to start aspirin 75 mg day, but he stopped taking these tablets because of stomach discomfort . The patient's total cholesterol was 228 mg dl (5.9 mmol l).

Coronory Heart Disease

Vegetarianism and Coronary Heart C. Foods, Nutrients, Vegetarianism and Coronary Heart Disease 45 A. Coronary Heart Disease in B. Coronary Heart Disease in Vegetarian South Asians 47 Coronary heart disease (CHD) is the major cause of death in most Western countries, and is rapidly becoming a major cause of death in developing countries too. Lopez and Murray1 predicted that, by the year 2020, CHD will be the leading cause of disease worldwide. Differences in the diets consumed by different populations account for much of the observed variation in CHD mortality rates, and the effect of vegetarian diets on CHD is a topic of great interest. The role of triacylglycerol as an independent risk factor for CHD has been uncertain, because adjustment for HDL cholesterol has tended to reduce or eliminate the association. However, a recent meta-analysis of prospective studies has shown that triacylglycerol is an independent risk factor for CHD Austin et al.27 found that, after adjustment for...

Influence Of Concomitant Coronary Artery Disease On Left Ventricular Remodeling

The influence of concomitant coronary artery disease on left ventricular remodeling can be observed in table 4. Patients with coronary artery disease, which was defined as a more than 50 stenosis in one of the epicardial coronary arteries showed equal transvalvular gradients, left ventricular ejection fraction and left ventricular volumes during two years follow-up. However, early postoperative left ventricular mass index was higher in patients with coronary artery disease and decreased less than in those patients who did not have significant coronary atherosclerosis (p

Cyanotic Heart Disease

TOF is defined as pulmonary stenosis, VSD, dextroposition of the aorta (overriding), and right ventricular hypertrophy. It is the most common cyanotic congenital heart disease. Presentation. Transposition is the most common congenital heart disease to present with cyanosis in the first 24 h of life. Symptoms of cyanosis and heart failure present within hours to days after birth. The second heart sound may be single and loud. A murmur may or may not be present.

Acute Coronary Syndrome

The term acute coronary syndrome refers to a category of patients presenting with chest discomfort in whom there is a high clinical index of suspicion that the source of the chest discomfort is ischemic heart disease. This category encompasses patients with unstable angina, NSTEMI, and STEMI. It is a useful term clinically because often the source of chest discomfort is not clear at the time of presentation, and deciding that the patient has to be approached as potentially being an acute coronary syndrome determines the pathway of evaluation and treatment that we will follow. More on that in a later chapter.

NonST Segment Elevation Myocardial Infarction

Non-ST Segment Elevation Myocardial Infarction 75 Figure 9.13. Presenting ECG of a patient with NSTEMI. Note the absence of any clear indication of an acute coronary syndrome on this ECG. Figure 9.13. Presenting ECG of a patient with NSTEMI. Note the absence of any clear indication of an acute coronary syndrome on this ECG.

Prevention of coronary heart disease in women

Case 2 a 65-year-old woman presents for new patient evaluation after a recent hospitalization for an inferior myocardial infarction (MI). She was treated acutely with angioplasty and stent placement in the right coronary artery. She also has a 30 left anterior descending coronary artery lesion and a 20 circumflex lesion. Her ejection fraction is 40 . She has had no further angina and denies symptoms of congestive heart failure. She smokes half a pack of cigarettes per day and proudly tells you this is much less than she used to smoke. She has no other chronic medical problems. What can be offered in each of these cases to reduce the patients' coronary heart disease (CHD) risk risk of CHD reoccurrence

Vitamin E and Cardiovascular Disease

Cardiovascular disease (CVD) is a general term for diseases that affect the heart and or blood vessels coronary heart disease, stroke, peripheral vascular disease, and high blood pressure. Oxidation of low-density lipoprotein (LDL) is considered to be a major causative factor in development of CVD (1). As reviewed by the Panel on Dietary Antioxidants and Related Compounds (1), vitamin E has the following effects that may impact the in vivo development of CVD Since publication of the DRI report, results of several large clinical intervention studies that support the DRI Panel conclusion have been published (Table 2.8). These include the Age-Related Cataract and Vision Loss Study (AREDS Report No. 9) (84), the Primary Prevention Project (PPP) (85), the MRC BHF Heart Protection Study (HPS) (86), the Antioxidant Supplementation in Atherosclerosis Prevention Study (ASAP) (87-89), and the Secondary Prevention with Antioxidants of Cardiovascular Disease in Endstage Renal Disease (SPACE)...

Heart Attack And Cardiopulmonary Resusciation 21 Definitions

A heart attack (myocardial infarction) is the death of heart muscle tissue caused by a blood clot (thrombus) or other substance circulating in the blood (embolus) that blocks one or more of the coronary arteries (arteries that provide the heart muscles with oxygen-rich blood).

Predisposing Factors Of Heart Attack Risk Factors

Disease related to the heart and blood vessels are the greatest killers of people in this country. According to a 2005 American Heart Association study, sudden cardiac death from coronary heart disease occurs over 900 times per day in the United States. The risk in adults is estimated to be about 1 per 1,000 adults 35 years of age and older per year. Sudden cardiac death in the young (people less than 35 years old) is much less common than in older adults, occurring in only 0.5 to 1 per 100,000 per year. A review of published studies that report initial heart rhythms during cardiac arrest in children indicates that the majority (40 to 90 percent) of children have asystole (a-SIS'to-le) or pulseless electrical activity when first evaluated. However, ventricular fibrillation or ventricular tachycardia (ven-TRIK'u-ler tak eh-KAR'de-ah) is found in about 7 to 14 percent of all children in cardiac arrest in the prehospital setting. About 60 to 70 percent of people who suffer myocardial...

Prophylactic Lidocaine Use In Heart Attacks

The objective of the meta-analysis is to determine whether there is a detrimental effect of lidocaine on mortality for hospitalized patients with a confirmed heart attack. The primary data include six studies and are reported in Table I. To begin, assume that each estimated risk difference, dt, is

Flavonoids and coronary artery disease

Consumption of flavonoids in the diet was previously shown to be inversely associated with morbidity and mortality from coronary heart disease (Hertog et al. 1995). The average daily human intake of flavonoids varies between as low as 25 mg to as high as 1g (Hertog et al. 1993a Leibovitz and Mueller 1993 Hollman 1997 Bravo 1998 de Vries et al. 1998). Following oral intake, some of the ingested flavonoids are absorbed from the gastrointestinal tract, and some of the absorbed flavonoids are metabolized by the gastrointestinal microflora. The bioavailability and metabolic modifications of flavonoids determine the antioxidative capacity of these potent antioxidants in vivo. Different classes of flavonoids are present in different fruits and vegetables, and also in beverages such as tea and wine. Flavonoids may prevent coronary artery disease by inhibiting LDL oxidation, macrophage foam cell formation and atherosclerosis (Rice-Evans et al. 1995 Catapano 1997 Aviram and

Alcohol and cardiovascular disease

The vast majority of cardiovascular deaths in Europe are from coronary heart disease and from cerebrovascular disease (stroke), with the proportion of each varying between countries. Stroke can be caused either by a blood clot in the cerebral circulation (ischaemic strokes) or by brain haemorrhage (haemorrhagic strokes). Cardiovascular diseases deserve more attention for two reasons first, cardiovascular diseases are the most common cause of death in middle-aged and older groups in most countries second, the association between alcohol consumption and cardiovascular diseases is complex and not yet fully understood. Results of the numerous studies of alcohol and coronary heart disease are remarkably consistent (for reviews, see Marmot 1984 Marmot and Brunner 1991 Royal College of Physicians 1995 Rimm et al. 1996 Doll 1997 Fagrell et al. 1999 Corrao et al. 2000). The evidence suggests that the relation between alcohol and both coronary heart disease and stroke follows a U-shaped or...

Heart disease

C.B. is a 58-year-old woman who presents for hospital follow-up. She is now four weeks after her first heart attack and still stunned that this happened to her. At hospital discharge, she declined cholesterol-lowering medication, saying she really doesn't want more drugs. She asks what she can do with her diet to reduce her risk of another heart attack. Limitation of dietary fat intake may be helpful in controlling serum lipids and thereby reducing risk of progression of coronary artery disease. The type of fat is important.1 Epidemiologic and other studies have documented strong correlation between saturated fat intake (as a percentage of calories) and coronary death rates. Replacing saturated fat with unsaturated fat is more effective than simply reducing total fat consumption in lowering heart disease risk. Monounsaturated fat intake is associated inversely with risk of heart disease. Coronary death rates are very low in Mediterranean populations that use olive oil as the primary...

Chronic ST Depression

Some patients with coronary artery disease have persistent imbalances between oxygen supply and demand that are reflected as chronic ST depression on the ECG. Thus, these patients display ST depression even on the resting electrocardiogram in the absence of pain (Figure 10.7). Figure 10.7. Chronic ST Depression. This 76-year-old male patient demonstrates chronic ST depression that persists from tracing to tracing in the high lateral wall (I, aVL, V5, and V6). Note that the downsloping ST depression forms an abrupt angle with the T wave, and that the T wave itself is altered by the ischemia. This patient also demonstrates evidence of a previous anterior myocardial infarction, in the form of pathologic Q waves in V1-V3. Figure 10.7. Chronic ST Depression. This 76-year-old male patient demonstrates chronic ST depression that persists from tracing to tracing in the high lateral wall (I, aVL, V5, and V6). Note that the downsloping ST depression forms an abrupt angle with the T wave, and...

Answers and Case Discussion

This middle-aged white female had significant risk factors in the form of obesity, hypertension, and diabetes, even though no family members were known to have had a myocardial infarction. Although the description of her pain, its radiation, and the way she related the pain to a fatty meal could suggest gallbladder disease, it is also entirely compatible with AMI. Nausea, vomiting, diaphoresis, and a mild sensation of shortness of breath could be common to both.

Identifying Candidates for Thrombolysis

You learned in Chapter 9 that the changes of LBBB can simulate, but can also mask, an acute anterior myocardial infarction. For this reason, patients presenting with new LBBB and a history compatible with AMI should also be strongly considered for thrombolytic therapy. As we learned in Chapter 10, patients with true posterior myocardial infarction may also be having a transmural STEMI, in which the evolution

Electrocardiographic Hallmarks of STEMI

Segment Types Ami

The evolution of an inferior wall myocardial infarction, as seen in lead III of a 55-year-old white male, Note that the admission tracing shows only ST elevation, A Q wave is beginning to form by 1 hour, and ST elevation is on the way down, By 24 hours, Q wave formation is complete, and the T wave is fully inverted, By 1 year, a pathologic Q wave is the only remaining evidence of infarction, Figure 9.3. The evolution of an inferior wall myocardial infarction, as seen in lead III of a 55-year-old white male, Note that the admission tracing shows only ST elevation, A Q wave is beginning to form by 1 hour, and ST elevation is on the way down, By 24 hours, Q wave formation is complete, and the T wave is fully inverted, By 1 year, a pathologic Q wave is the only remaining evidence of infarction,

Other Pitfalls to Diagnosing AMI Ventricular Aneurysm

Signs After Anterior Infarction

Produces Q waves in the anterior precordial leads, along with upward slurring of the ST segment. This combination can simulate the ST segment elevation of acute anterior wall infarction. But the converse is also true. Some patients with extensive anterior wall infarctions develop LBBB because of extensive necrosis of the septum. Indeed, diagnosing anterior wall myocardial infarction in patients with LBBB is so perilous that the safest course for all but the most experienced electrocardio-graphers is to never try to make an electrocardiographic diagnosis of anterior wall myocardial infarction in patients with LBBB. In this situation, the clinical presentation becomes all-important, as we will discuss in Chapter 11. The availability of an old tracing on file is also of paramount importance, so that one may establish whether or not the LBBB is new. Figure 9.19. Evolving anterior wall myocardial infarction in the presence of LBBB. Note that the T waves in lead V2 are concordant, meaning...

Localization of Infarction

You will recall from Chapter 3 and from your knowledge of the hexaxial reference system (Figure 9.4) that leads II, III, and aVF are called the inferior leads because they look up at the heart from below. When the typical evolution of the three hallmarks of STEMI is seen in II, III, and aVF, we label it an inferior wall myocardial infarction.

Right Ventricular Hypertrophy

Fully developed RVH with a strain pattern in the leads that look at the right ventricle, namely the right-sided precordial leads.This tracing is from a 12-year-old female with congenital heart disease and a single right ventricle. Figure 8.5. Fully developed RVH with a strain pattern in the leads that look at the right ventricle, namely the right-sided precordial leads.This tracing is from a 12-year-old female with congenital heart disease and a single right ventricle.

Intermittent ST Depression

As you learned earlier in this chapter, ischemia is usually a changing, dynamic state that comes and goes, depending on the current balance or imbalance between oxygen supply and oxygen demand in the tissues. By the same token, ST depression is also often transient. It comes and goes with the ischemic state. Many patients with severe coronary artery disease display perfectly normal ECGs at rest and demonstrate ST depression only when ischemia is precipitated by exercise or occurs during an anginal episode. This fact gave rise to exercise stress testing as a means of detecting occlusive coronary artery disease in patients with normal resting ECGs. During stress testing, a 12-lead ECG is continuously monitored while the patient walks on a treadmill or peddles a stationary bicycle. Any ischemia provoked by exercise is then detected by observing for horizontal or downsloping ST depression of 1 mm. Care must be taken not to falsely interpret physiologic J point depression as representing...

The Role of History Taking

The clinical presentation of ischemic heart pain remains one of the most diverse in medicine. Nevertheless, studies have demonstrated that a history taken by an experienced clinician is a more accurate predictor of ischemic heart disease than any single available test, with the exception of coronary arte-riography. For this reason, an accurate history taken by a well-trained ACLS provider is paramount to the evaluation of the patient presenting with chest pain. In most instances, it is the history that will trigger the provider's decision to move the patient along a path of evaluation for ischemic heart disease.

Differential Diagnosis of ST Elevation

Deszendierende Streckensenkung

Acute myocardial infarction is not the only condition that can cause ST-segment elevation. Several other conditions, including pericarditis and benign early repolarization changes (a normal variant of ST elevation commonly seen in healthy young adults), routinely produce ST elevation. It is important, therefore, to distinguish STEMI from other causes of ST elevation.

Pathophysiology of Ischemia

In coronary artery disease, incomplete obstruction of the coronary arteries with atherosclerotic plaque limits myocardial perfusion. Under circumstances of rest, the diminished flow of oxygenated arterial blood may still be sufficient to meet the metabolic needs of the myocardium. However, during periods of exercise, the needs of the myocardium may require a greater volume of blood than can be delivered through the partially obstructed coronary arteries. In short, myocardial oxygen consumption may outstrip oxygen supply. The result is ischemia of the myocardium.

Differential Diagnosis of ST Abnormalities

Finally, clinical correlation, as always, is also helpful. For example, ST depression appearing with chest pain and resolving when the chest pain resolves makes the diagnosis of ischemia a virtual certainty. The clinical and ECG correlates of ischemic heart disease will be the subject of our next chapter.

Prevention of Thromboembolism

Anticoagulation with warfarin is clearly indicated for high-risk patients with AF, who are defined as those older than 65 years of age or with underlying heart disease. Other higher-risk groups include those with hyper-thyroidism or diabetes, as long as there are no contraindications to warfarin. Certain patients are not considered to be good candidates for warfarin therapy. These include elderly individuals who fall frequently or patients who chronically abuse alcohol. If anticoagulation cannot be used, such patients should be treated with aspirin, 325 mg per day. heart disease or hypertension. Such patients can probably be treated with aspirin, 325 mg, instead of warfarin because of their low risk of embolization.56 Although aspirin is not as effective as warfarin in preventing stroke, the increased risk of bleeding associated with warfarin use cancels out its benefit in these patients in whom the risk of stroke is low.

Ventricular Arrhythmias

Prudent medical practice dictates that therapy for PVCs be based on the company they keep (Table 9). They are common in the general population, and if no heart disease is present, they are generally benign. Accompanying conditions that increase catecholamine levels, as well as hypoxia, electrolyte abnormalities, and drug toxicity, should be treated. If, however, the PVCs occur with acute ischemic heart disease or any other organic heart disease, they may be of greater signifi cance. PVCs themselves are not a cause of mortality, unless they lead to sustained VT or VF. Clinically, one should look first for disorders associated with increased catecholamine levels, hypoxia, electrolyte abnormalities, drug toxici-ty, HF, and ischemia. These conditions should be corrected if they exist. If PVCs persist, Holter monitoring could be considered in an attempt to determine if more malignant forms are present. In the absence of underlying heart disease, PVCs,...


You and your ACLS partner have just made your way through the cafeteria line and are sitting down to roast beef and lemon meringue pie when the tones go off. You are dispatched to a local residence for chest pain. Upon arrival, you recognize a familiar face. Mr. Saunders, who is 64-years-old, is well known to you, having a long history of coronary artery disease and having been transported to the hospital with chest pain three or four times in the last year and a half. His wife mentions to you that he was just discharged from the hospital two weeks ago after another heart attack. Mr. Saunders reports to you that he is having retrosternal heaviness similar to that he has had in the past when he had heart attacks. You quickly note as you are placing him on oxygen that his skin is warm and dry, and that he does not appear dyspneic. As your partner connects him to the cardiac monitor, Mr. Saunders relates that he has had the pain approximately 15min, but...

Q Wave Formation


Acute inferior wall myocardial infarction showing pathologic Q wave formation and ST elevation in II, III, and aVF. A pathologic Q wave can also be seen in leads V, and V2, denoting an old anterior wall infarction, Figure 9.9. Acute inferior wall myocardial infarction showing pathologic Q wave formation and ST elevation in II, III, and aVF. A pathologic Q wave can also be seen in leads V, and V2, denoting an old anterior wall infarction, normally seen in the inferior leads II and aVF particularly. Q waves will also be seen in lead III with LPH. With acute inferior wall infarction, however, the Q becomes deeper and wider until it reaches criteria for becoming what elec-trocardiographers call a pathologic Q wave. Most electrocardiographers define a pathologic Q as being at least 0.04 s wide (one small block) with a depth 25 of the height of the R wave. Thus,the presence of a Q wave alone in the inferior leads is not enough to diagnose an inferior wall infarction, unless the...

Pathogenesis of AMI

In the mid 1960s, most respected pathologists held the view that AMI was the result of fixed obstructive disease of the coronary arteries, and that clot formation rarely played a role in AMI. In fact, at that time the old term coronary thrombosis was dropped from the lexicon, and the familiar term myocardial infarction substituted in its place. Figure 12.1. Schematic diagram showing the order of necrosis through the ventricular wall in AMI, Note that the endocardium necroses much faster than the epicardium because of less abundant collateral circulation, (Modified from Swan HJC, Anderson JL, et al, Practical Aspects of Thrombolysis in the Clinical Management of Acute Myocardial Infarction, American College of Cardiology,) Figure 12.1. Schematic diagram showing the order of necrosis through the ventricular wall in AMI, Note that the endocardium necroses much faster than the epicardium because of less abundant collateral circulation, (Modified from Swan HJC, Anderson JL, et al,...

Q Waves as Scars

Crown Infarction

It was mentioned earlier in the chapter that the ST elevation and T wave inversion seen in STEMI frequently resolve over time, but that the Q wave may persist indefinitely as evidence of a past infarction. Pathologic Q waves in the absence of AMI are therefore sometimes referred to in ECG reports as scars or remote infarctions. Figures 9.10 and 9.11 show remote inferior and anterior infarctions, respectively, in which the ST elevation and T wave inversion have resolved but Q waves persist as evidence of the old infarction. Close inspection of the acute inferior myocardial infarction shown in Figure 9.9 also reveals a pathologic Q wave in V and V2, indicating an old anteroseptal wall infarction. Figure 9.10. Remote inferior wall myocardial infarction showing pathologic Q wave formation in leads III and aVF. Figure 9.11. Remote anterior wall myocardial infarction showing pathologic Q wave formation in Vq-V3. Although there is still slight ST elevation that has persisted, as is sometimes...

ST Elevation

Acute Inferior Myocardial Infarction

Acute anterior wall myocardial infarction. Note that, in addition to ST-segment elevation across the anterior precordial leads, there is reciprocal depression seen in leads III and aVF. Also note that, in this particular patient, the ST elevation is slightly upwardly concave, Figure 9.6. Acute anterior wall myocardial infarction. Note that, in addition to ST-segment elevation across the anterior precordial leads, there is reciprocal depression seen in leads III and aVF. Also note that, in this particular patient, the ST elevation is slightly upwardly concave,

Anterior Wall STEMI

Anterior myocardial infarction occurs as the result of occlusion in the distribution of the left coronary artery. It is commonly a larger infarction, and may be associated with sinus tachycardia, pump failure, higher degrees of heart block (Mobitz type II or third degree), or with new BBB. Higher degrees of heart block occurring with anterior myocardial infarction carry a bad prognosis because they are usually the result of extensive infarction with necrosis of the ventricular septum and the bundle of His or the bundle branches. Pacing is usually required for these higher degrees of heart block, but rarely alters outcome because these patients typically die of pump failure as a consequence of the extensive nature of the infarction.

The ECG as a Tool

Correlation of the ECG with the clinical presentation is never more important than when approaching the patient with potential ischemic heart disease. In this chapter, we will discuss in detail the clinical presentation of the various syndromes associated with ischemic heart disease and the clinical approach to this group of patients.

Case Presentations

This section is designed to give you some practice in implementing your newfound knowledge in making clinical decisions regarding the patient with a potential acute coronary syndrome, much as ACLS megacodes permit you to practice resuscitation. There are 12 practice case presentations. You will have the opportunity to make decisions in a sequential fashion, much as you would do in real-life clinical situations. Sometimes you will be functioning in the prehospital environment, and sometimes in the emergency department or coronary care unit. For purposes of this section you should assume that the phrase prehospital thrombolytic protocol refers to (1) starting two IVs, (2) drawing blood specimens for laboratory analysis in the process of starting the IVs, and (3) administering one aspirin to be chewed all of these in preparation for potential thrombolysis in the emergency department.


Like any muscle, when called upon to work harder than is normally required, cardiac muscle will enlarge, or hypertrophy. The cause is typically either an increased resistance to outflow of blood from the chamber (as in stenosis of a valve or hypertension), or the requirement to handle increased volumes of blood (as in regurgitation of blood across an incompletely closed valve or in many forms of congenital heart disease).

T Wave Inversion

Evolving anterior wall myocardial infarction showing loss of R wave progression in V2-V4. Slight ST elevation remains, and there is prominent T wave inversion in leads V2-V5,1, and aVL. Figure 9.7. Evolving anterior wall myocardial infarction showing loss of R wave progression in V2-V4. Slight ST elevation remains, and there is prominent T wave inversion in leads V2-V5,1, and aVL.

Inferior Wall STEMI

Inferior myocardial infarction occurs with occlusion of the right coronary artery. It is commonly associated with a significant vasovagal response characterized by marked sinus bradycardia and hypotension that is usually responsive to atropine and volume expansion. Sinus bradycardia may be further aggravated by a diminution in perfusion to the SA node. AV block, when seen with inferior myocardial infarction, is typically lower grade (first degree or Mobitz type I) and is the result of edema of the AV node, as opposed to necrosis. Because the level of block is in the AV node, even when block advances to third degree there is typically a reliable junctional escape rhythm present. Pacing is not usually required, and symptomatic bradycardia can usually be adequately treated with atropine. Pump failure is less often a problem than with anterior myocardial infarction, unless the patient has a more extensive than usual right coronary circulation or has lost muscle mass from a previous...

Anginal Syndromes

Myocardial ischemia can also occur without producing chest pain. Many patients with coronary artery disease have frequent periods of silent ischemia occurring in the absence of chest pain. Coronary artery spasm is another cause of myocardial ischemia, and has been labeled variant angina or Prinzmetal's angina. Variant angina can occur even in patients with completely clean coronary arteries, although, more often, spasm occurs in the immediate vicinity of atherosclerotic plaque in patients with coronary artery disease. Spasm diminishes perfusion and can produce exactly the same ischemic consequences as atherosclerosis. Cocaine is a well-documented precipitator of coronary artery spasm that can induce a clinical picture of ischemic chest discomfort that is indistinguishable at presentation from other acute coronary syndromes. Typically, the patient presenting with cocaine-induced coronary spasm will be a male under 40 years of age, a smoker, will have used cocaine within several hours...

Treatment of NSTEMI

DeWood MA, Spores J, Notske R, et al. Prevalence of total coronary artery occlusion during the early hours of transmural myocardial infarction. N Engl J Med. 1980 303 897-902. 3. Hochman JS, Sleeper LA, Webb JG, et al. For the Should We Emergently Revas-cularize Occluded Coronaries for Cardiogenic Shock (SHOCK) Investigators. Early revascularization in acute myocardial infarction complicated by cardio-genic shock. N Engl J Med 1999 341 625-634. infarction radionuclide results from the Myocardial Infarction Triage and Intervention Trial. Abstract . Circulation. 1992 86 643. 5. Gruppo Italiano per lo Studio della Streptochi-nasi nell'Infarto Miocardico (GISSI). Long-term effects of intravenous thrombolysis in acute myocardial infarction a final report of the GISSI study. Lancet. 1987 2 871-874. 7. Fine DG, Weiss AT, Sapoznikov D, et al. Importance of early initiation of intravenous streptokinase therapy for acute myocardial infarction. Am J Cardiol. 1986 58 411-417. 8. Gruppo Italiano...


Tracing from a 59-year-old white male taken at 9 23 AM during streptokinase administration for acute inferior wall myocardial infarction. Note typical prominent ST elevation in the inferior wall, with reciprocal depression in leads I, aVL, and V1 and V2. B. Second tracing from the same patient taken 7min later, at 9 30 AM, after sudden relief of pain. Note substantial resolution of ST-segment elevation and reciprocal depression that has occurred with reperfusion. Figure 12.5 A. Tracing from a 59-year-old white male taken at 9 23 AM during streptokinase administration for acute inferior wall myocardial infarction. Note typical prominent ST elevation in the inferior wall, with reciprocal depression in leads I, aVL, and V1 and V2. B. Second tracing from the same patient taken 7min later, at 9 30 AM, after sudden relief of pain. Note substantial resolution of ST-segment elevation and reciprocal depression that has occurred with reperfusion.


Reperfusion is usually accompanied by diminution of ST-segment elevation, particularly in cases that reperfuse early. Figure 12.5A is the tracing of a 59-year-old white male with acute inferior wall myocardial infarction taken at 9 23 AM during administration of streptokinase. Figure 12.5B is from the same patient, taken 7min later at 9 30 AM, after sudden relief of pain. Note that substantial resolution of both ST-segment elevation and reciprocal depression has occurred with reperfusion. Late reperfusion, after substantial necrosis has occurred, is less likely to produce resolution of ECG changes.


Algorithm for a suggested approach to cost-effective, risk-stratification and management after acute myocardial infarction (MI). This approach entails risk stratification and initiation of preventive therapy in all patients before discharge, including those without symptoms. Patients with persistent or recurrent symptoms of cardiac failure, ischemia, or ventricular arrhythmias (unstable condition) should undergo direct coronary angiography, followed by myocardial revascularization (percutaneous transluminal coronary angioplasty PTCA or coronary artery bypass graft surgery CABG when appropriate). Patients who appear clinically stable after an acute MI may or may not have evidence of left ventricular (LV) dysfunction. Patients with no evidence of LV dysfunction should undergo submaximal treadmill exercise testing (ET). Patients with evidence of LV dysfunction should undergo echocardiography to assess LV function. If ejection fraction is 40 percent, ET should be performed to detect...


Digoxin prolongs the refractory period of the atrioventricular (AV) node, resulting in a slowed ventricular response to supraven-tricular tachyarrhythmias, especially atrial fibrillation, for which digoxin remains an agent of choice, especially when the fibrillation accompanies acute myocardial infarction or LV failure. Digoxin also ameliorates the autonomic dysfunction typical of HF by attenuating SNS activity.

Other HF Therapies

Ventricular arrhythmias are often present in patients with HF. Despite their ubiquity, treatment should be limited to potassium and magnesium supplementation for asymptomatic premature ventricular contractions (PVCs), even if frequent, or for short periods of nonsustained ventricular tachycardia. In those patients who become symptomatic due to sustained ventricular tachycardia, medical therapy with agents such as amiodarone (Cordarone) may be indicated, or, in the more refractory cases, consideration may be given to implantation of a cardioverter-defibrillator.19 Among other ancillary therapies for managing HF are nitrates or anticoagulants. Both are discussed at greater length under management of acute myocardial infarction (MI). The patient with a significant heart murmur who develops HF should be evaluated for the possibility of valve replacement. In selected circumstances, surgical correction of the valvular abnormality will resolve the HF. Admittedly, it...

Atrial Fibrillation

The most frequently occurring sustained cardiac arrhythmia, AF, is seen at least in 2 to 5 percent of older individuals. New-onset AF is most often associated with ischemic heart disease, hypertension, or HF (with which it has a unique relationship since HF can both cause and be the result of AF). Other causes of new-onset AF are listed in Table 8.

And Complicated Plaques

However, during its maturation process the plaque may become vulnerable and predisposed to ulceration and or rupture 12, 19 . Once a plaque becomes ulcerated and disrupted, the coagulation cascade is initiated, with formation of platelet-rich white thrombi, that differ from the red thrombi formed in regions of stasis or low flow. Despite simultaneous endogenous thrombolysis, the initial small mural thrombus may evolve to a major, near-occlusive thrombus. It may also embolize, resulting in distal small vessel occlusion leading eventually to massive arterial occlusion. In these circumstances, acute clinical conditions may occur, with the onset of a wide range of symptoms including rapidly installing unstable angor pectoris, myocardial infarction, transient ischaemic attack, or toe gangrene.

Preface To Valve Surgery At The Turn Of The Millennium

Valvular heart disease remains a major cause of morbidity and mortality and is the third most common problem in cardiology and the second in cardiac surgery. About 10 of cardiac surgical cases deal with valve disease and a far greater number of patients are followed closely of which some are treated medically. In the field of management of valvular heart disease exciting advances have been made. Was invasive evaluation the cornerstone in the examination and diagnosing of patients in previous decades, in the past 10 to 15 years non-invasive methods for diagnosis of the disease and evaluation of disease severity have been developed and validated. Echocardiography is widespread used for this purpose and has greatly improved assessment of valvular lesions, its severity and the consequences of the valvular dysfunction. Echocardiography has in the last decades, not only greatly improved our knowledge of valvular heart disease but also replaced the invasive pre-operative evaluation of almost...

Lipids and Peripheral Arterial Disease

Peripheral arterial disease (PAD) is associated with a high risk of vascular events 1, 2, 14, 18, 19, 31, 32 . This is true whether PAD is symptomatic or asymptomatic. This risk is so high that PAD is considered as a coronary heart disease (CHD) equivalent 5, 13 . It follows that these patients need to have their modifiable vascular risk factors controlled. Dyslipidaemia, a modifiable vascular risk factor, should be treated aggressively with lipid-lowering drugs, according to international guidelines 5, 13, 16, 37 . The earlier low density lipoprotein-cholesterol (LDL-C) targets European LDL-C target

Endoluminal Treatment of Infrarenal Abdominal Aortic Aneurysm

The patient had a significant previous medical history, which included ischaemic heart disease, severe chronic obstructive lung disease, and several previous laparotomies. He had undergone coronary artery bypass graft (CABG) surgery a few years ago. On examination, the patient was haemodynamically stable with no abdominal complaints. There was an expansile pulsatile mass palpable in his obese abdomen, and all peripheral pulses were palpable.

Evaluation Of The Cause Of Mr

Significant MR without abnormalities of the valve leaflets or annular dimensions is seen in acute myocardial infarction due to alterations in regional left ventricular function and shape5. Most often the infarction is located in the flow area of the right or circumflex coronary artery and is associated with inferior wall motion abnormalities6. On 2 DE the posterior leaflet slides under the anterior and a MR jet is directed anteriorly. The effect of reperfusion on these ischemic MR's remains controversial and depends on the mechanism of MR when annular dilation associated with inferior wall motion abnormalities is present, reperfusion alone is not enough to achieve valve competence and annuloplasty is needed4,7,8.

Factors Influencing Timing Of Surgery

Several variables have been described to influence outcome after surgery for severe MR. Besides echocardiography variables, these include age, functional class I, presence of coronary artery disease l7,23 and hemodynamic variables as mean pulmonary artery pressure and cardiac index24. The echocardiography markers indicating poor outcome were ESD 45-50mm17,23,25 and EF 50-60 l7,23. One must be aware that these variables are derived from studies where they identified patients with poor outcome after surgery. So, in no way it is proven that they point out accurately the onset of occult left ventricular dysfunction still being reversible. In this respect, is a significant change from baseline of ESD and EF a much stronger indicator of the onset of contractile dysfunction and should lead to prompt referral for surgery, than the reaching of the values of the absolute parameters per se. The values mentioned are only indications for patients who are asymptomatic and seen for the first time.

What are the physical consequences

Now I have the complications, I've had a heart attack and a bypass, only now I realise that it's not such a great thing to have after all, but you just cope and try to lead a normal life, I have to be more careful now.' Complications are conditions that arise as a result of having diabetes. Some are short term, for example hypoglycaemia (low blood glucose), hyperglycaemia (high blood glucose) and ketoacidosis (very high blood glucose). Others are more long term and develop gradually over time and include heart disease, high blood pressure, damage to the kidneys, and eye and nerve damage. immediately. The importance of this cannot be overemphasised, and that knowledge may help to give you the incentive you need to stop or drastically reduce your smoking habit. This chapter will discuss the physical consequences of diabetes, in particular the short-term complications which include hypoglycaemia, hyperglycaemia and diabetic ketoacidosis (DKA) and how they can be avoided and treated. The...

Cardiovascular System

Daemia) are also risk factors for coronary artery disease (CAD). The incidence of CAD in patients with peripheral vascular disease is around 60 . The usual symptomatic presentation in this group of patients may be obscured by exercise limitations due to advanced age or intermittent claudication.

Studies in Seventh Day Adventists

These studies are reviewed below. However, as early as 1958, Wynder and Lemon examined cancer and heart disease in SDA hospital patients compared with non-SDA patients.18 In this early study, based on 564 SDA and 8128 non-SDA patients admitted to eight SDA hospitals throughout the U.S., lower risk of epidermoid lung, mouth, esophagus, larynx, and bladder cancer were found in the SDAs than in the non-SDAs. Colon and rectum cancer, however, were not found less frequently in the SDA than the non-SDA comparison group, while prostate and breast cancer were found somewhat more frequently in the SDA patient series. Interviews with study subjects indicated that only 41 of the SDA patients consumed any meat, whereas 95 of the general population consumed meat.

The Troglitazone in the Prevention of Diabetes Study

Clearly, these trials have demonstrated the important role of lifestyle changes including both diet and exercise in altering the progression of glycemic tolerance. Further discussion of the importance of these studies in outcome reduction for cardiovascular disease will be discussed in Chapter 12.

A Anastomotic Aneurysms

A 70-year-old woman presented with bilateral pulsatile groin masses (Fig. 9a.1). Six years ago, she had an elective aorto-bifemoral graft for a 6-cm abdominal aortic aneurysm involving both iliac arteries, from which she made a full recovery. She first found the larger, right-sided mass 4 months ago, and she had noted gradual enlargement since then. She had no symptoms of claudication or leg ischaemia. Her past medical history included a myocardial infarction (MI) 18 months ago, but without limitation to her exercise tolerance.

Testosterone Deficiency

He suffers from coronary artery disease and regularly takes antianginal medications. One month ago, he began to take Metabolife 356 for weight loss and to increase his energy level. He drinks three cups of coffee a day. Stop ephedrine containing supplement and educate on risks of unsupervised use of herbal alternative medicines evaluate for worsening coronary artery disease if symptoms do not abate after stopping the supplement.

Monocyte Chemoattractant Protein1

Animal studies suggest that MCP-1 could contribute negatively to cardiovascular disease. Blocking the MCP-1 pathway with gene therapy can prevent atheroma formation (117), as well as slow the progression of established lesions (111). The jury is still out, however, as to whether this adipokine contributes to the pathogenesis of atherosclerosis, or is merely a marker (115).

Monitoring for Cardiac Ischaemia

Due to the complexity and the possible side-effects of the two latter methods, the most practical and most used form is surface ECG. It is considered important to monitor ischaemia during and after the operation and to take measures to resolve the ischaemia if possible, to prevent myocardial infarction, although it is not shown to reduce peri-operative morbidity in controlled trials 51 . Subendocardial ischaemia is the most common type of ischaemia, and is detected by ST depression 37 , while transmural ischaemia causing ST segment elevation in the leads facing the lesion is less common. In noncar-diac surgery patients, 96 of ischaemic episodes were detected with a three-lead system (leads II, V4 and V5) 38 . ECG changes consistent with ischaemia are difficult to detect in patients with right bundle branch block, left ventricular hypertrophy with a strain pattern or with atrial fibrillation, and impossible in patients with left bundle branch block or on a pacemaker - this affects...

Perioperative Heparin

Administration of intravenous heparin before cross clamping in elective aortic surgery is widely used, and is considered to reduce peripheral thrombotic complications. This has however not been proven in a randomized trial of heparin versus placebo, where there was no difference in blood loss, blood transfusion or distal thrombosis. However, this study did show a benefit of heparin administration on peri-operative myocardial infarction - 5.7 in the placebo group versus 1.4 in the heparin-ized group 71 .

Postoperative Determinants For Late Survival After Mitral Valve Replacement

The effect of specific surgical techniques with respect to preservation of part of the subvalvular apparatus has not been incorporated into many of the publications on long-term survival. Rheumatic heart disease means by definition that in the majority of the cases, the severely abnormal subvalvular apparatus has been resected at the time of surgery. Resection of the chordal apparatus has a known negative influence on left ventricular function 45-49. If we regard the improved survival rate of mitral valve repair over replacement, as the difference in survival with and without subvalvular apparatus, it is obvious that the presence of the subvalvular apparatus is important for left ventricular function33. David found a ten-year survival rate of 80 with preservation of the subvalvular apparatus versus 63 survival for patients without chordal preservation. This holds true particularly for patients with mitral incompetence 45,46. The most common cause of death after mitral valve...

Longterm complications

The possibility ofdeveloping long-term complications is one ofthe most frightening aspects of diabetes. Prolonged periods of high blood sugar increase the risk of complications in people with diabetes. Common ailments include cardiovascular disease (such as high blood pressure and atherosclerosis), eye disorders, kidney disease, nerve disorders, and foot and leg problems. Most of these conditions result from years of chronic high blood sugar levels. The good news is that many ofthe possible problems can be treated, and often the treatment is most effective when the complications are noticed at an early stage. This is why you will be asked to go for regular medical check-ups.

Anesthesia for Vascular Surgery

Surgery of the peripheral vascular system requires technical precision and perioperative vigilance. The outcome of vascular procedures depends on various factors. These factors include patient selection, the procedure performed, the surgeon's skills, and the perioperative care. The importance of the perioperative care cannot be underestimated. Patients presenting with a vascular pathology often have comorbidities. The incidence of coronary artery disease (CAD) in patients with carotid disease is estimated at 50 .

Postoperative Thromboembolic Events And Bleeding

Thromboembolic events and bleeding are classified as non-cardiac, valve related events. Risk factors for thromboembolic events are mitral valve prosthesis, atrial fibrillation, enlarged left atrium, low left ventricular ejection fraction, history of prior thromboembolic events. Additionally coronary artery disease and the presence of a pacemaker increases the risk for thrombo embolic events up to four times 52,55. The incidence of thromboembolic events is reported to be between 0.9 and 2.1 per year for prosthetic mitral valves, after the initial three postoperative months have been passed. According to Cannegieter age is a significant factor 52,57. Atrial fibrillation without mitral valve disease is a major source of thromboembolic events and thus should be treated with oral anticoagulants. Stein suggests addition of low dose aspirin for patients with coronary artery disease and stroke 54. However, investigators from Leiden found in a meta-analysis no benefit from adding platelet...

Physiological and Mechanical Considerations

Aortic cross-clamping leads to an increase in cardiac afterload. This acute increase in after-load is both measurable and manipulable, directly and indirectly. Uncontrolled hypertension, although tolerated by the healthy heart, can lead to systolic or diastolic dysfunction and cardiac decompensation. Blood pressure is often viewed as dependent on circulating blood volume, cardiac preload and afterload, and cardiac function. All of these factors are influenced by, and essentially precluded by, the ability of the heart to withstand the stress of any acute physiologic change. The effects of aortic cross-clamping are initially mechanical due to abrupt change of afterload. The rough percent

Stress Testing And Exercise Tolerance

As the result of the increased cardiovascular risk in diabetic patients, exercise stress testing is vital to identifying blood pressure responses, arrhythmias, heart rate responses, and risk stratification in these patients. Ideally, patients need to burn a minimum of 1000 calories weekly with aerobic exercising and participate in resistance training. This should be achieved with a minimum of three sessions a week, with aerobic exercising gradually increasing to 45 minutes for maximum benefit. Each session should be preceded by a warm-up period and conclude with deceleration activities to allow for gradual transition from the higher demands of the accelerated phase of the workout (12).

Creactive Protein CRP

Preprocedural CRP levels predict a high incidence of myocardial infarction (MI) in patients with PAD, independently of previous CHD and established vascular risk factors 17 . CRP levels at baseline and 48 h after intervention may also be independent predictors of postan-gioplasty outcome (e.g. restenosis at 6 months 20 ).

Alternative Therapies

Sometimes all that may be necessary for incontinence therapy in the stroke patient will be simple behavioral modifications such as fluid restriction and initiating a timed voiding schedule both determined from a voiding diary. Many demented patients who no longer have socially appropriate behavior may also benefit substantially from a prompted voiding schedule. Gelber et al. (13) reported that 37 of

Clinical Implication Of Development Of Bmi Growth Curve

Obesity is increasingly common in the United States and a serious risk factor for decreased longevity and many medical disorders such as diabetes and cardiovascular disease 20 . According to the third National Health and Nutrition Examination Survey (NHANES-III), over half the U.S. adult population is overweight or obese 21 and the prevalence continues to increase 22 . From an epidemiologic point of view, BMI alone may not capture the true relations of body composition to health outcomes 23 because BMI does not distinguish between lean mass and fat mass. Nevertheless, BMI is highly correlated with weight and fat mass, and tends to be approximately uncorrelated with height. BMI is arguably the most commonly used index of relative weight in clinical trials and epidemiological studies of the health consequences of obesity 24 . Furthermore, BMI was the index adapted in the most recent NHLBI 'Clinical guidelines for the identification, education, and treatment of overweight and obesity in...

General Complications

And calcium antagonists are recommended (Table 2.1.2). A CT scan in patients with symptoms is recommended to exclude secondary haemorrhage and visualize cerebral oedema. Bradycardia sometimes in combination with hypotension is also frequently seen intraoperatively as well as in the immediate postoperative period. This has been attributed to increased activity from the carotid barore-ceptors related to increased stretch and compliance in the arterial wall after removal of the atherosclerotic plaque. History of myocardial infarction (MI) also predisposes to postprocedural hypotension probably due to increased sensitivity of baroreceptors in patients with coronary artery disease. This is important during CAS too, which also involves manipulation of baroreceptors and the carotid sinus and contributes to haemodynamic instability. Bra-dycardia during CAS can be severe and result in asystole unless treated. Hypotension in the post dilatation period is common and adequate postprocedural...

Guidelines For Exercise

Improved insulin sensitivity correlates with lowered cardiovascular risk. Weight loss combined with exercise and diet therapy significantly decreases intra-abdominal fat and is associated with a better sense of well-being, better mood, and higher self-esteem. The matter in which exercise is attempted is strictly the patient's preference. Clearly, low cardiorespiratory fitness increases mortality. A 2003 study in the Journal of the American Medical Association (21) from the Coronary Artery Risk Development in Young Adults (CARDIA) group indicated that poor fitness in young adults increases risk and enhances the development of cardiovascular risk factors and obesity, and that improving fitness can improve the risks. These results are similar to other studies where maximum oxygen uptake was used to measure fitness rather than treadmill-testing time. Nonetheless, it underscores the fact that suboptimal physical activity and fitness increase risk for cardiovascular disease, diabetes, lipid...

Chronic Ischemia Patient History

History-taking in the patient with lower extremity ischemia should also focus on symptoms of atherosclerosis in other vascular beds, particularly the cerebral and coronary circulation. Patients with symptomatic lower extremity ischemia have a 20 to 60 incidence of significant coronary artery disease, and the coexistence of cerebrovascular and lower extremity arterial occlusive disease is also well established. Symptoms of angina, congestive heart failure, and transient ischemic attacks or strokes should be diligently investigated as many patients may ascribe these symptoms to a nonvascular cause and may not volunteer this important information. The history should also include any prior events, such as blue or painful toes, which may be suggestive of an embolic cause of the ischemia.

Other Typical Postoperative Problems

5) Ischemia by postoperative air-embolism to the coronaries (typically to the right coronary artery) or direct damage of a coronary artery. In particular, the circumflex artery, which courses in the atrioventricular groove may be damaged during surgery. In the presence of coronary artery disease, acute occlusion of a vessel can also occur spontaneously. The hallmark of coronary ischemia is a regional wall motion abnormality. Ischemia by air-embolism usually resolves completely within minutes.

Combined Treatment of Coronary Plus Other Arterial Pathologies the Magnitude of the Polyatherosclerotic Patient

Atherosclerosis is a generalized disease 2, 4, 9, 11, 21, 22, 41 . Therefore, it is of no surprise that simultaneous atherosclerotic lesions may exist in the carotid arteries, the coronary arteries, the aorta and the peripheral arteries in the form of unifocal, bifocal and multifocal occlusive or aneurysmal disease 1, 14, 15, 18, 26, 38, 39 . Coexistence of severe coronary artery disease with carotid artery stenosis, aortic aneurysm and critical limb ischaemia is a frequent event and the management of these patients is still unclear and in some cases controversial 12, 16, 17, 24, 27, 31, 32, 36, 37 . Therefore, multifocal atherosclerosis remains a challenge for the cardiothoracic and vascular surgeon who has, nowadays, the therapeutic alternative of open or endovascular repair. Severe coronary artery disease - 198 patients. The main focus of the study was the need to modify the initially planned treatment as a result of other vascular priorities this proved to be necessary mainly in...

Multifocal Carotid and Coronary Occlusive Disease

Stroke is a devastating complication of coronary bypass surgery and is associated with significant mortality (20 ). There has been a debate over the last 25 years concerning the relationship between carotid endarterectomy and CABG. Which one has priority This issue remains controversial but becomes more demanding with the passing of time. This is because there the population needing CABG is ageing, which in consequence increases the coexistence of carotid and coronary artery disease. Although there is now a significant reduction in the morbidity and mortality following myocardial revascularization, the incidence of post-operative stroke in patients undergoing coronary surgery has remained unchanged. This observation can be explained by the fact that the causes of perioperative stroke after CABG are multifactor. They include to give a clear result in terms of stroke without warning 1 . The results of the ACST study (Asymptomatic Carotid Stenosis Trial) have recently been published....

Meat And The Pathology Of Human Disease

The fat in red meats has been identified as having a very high content of saturated fat (Table 7.2). Thus, based on fat content alone, red meat could be considered an atherogenic risk factor that contributes to coronary heart disease and ischemic strokes. A number of prospective studies have linked red meat intake to higher rates of coronary heart disease and stroke.18-22 Recent laboratory data also raise the possibility that the low polyunsaturated to saturated fat ratio in red meats (Table 7.2) increases the permeability of the cell membrane to insulin receptors and thus increases insulin resistance.23-25 This mechanism suggests that increased red meat intake (relative to other meats or no meat intake) could potentially produce a hyperinsulinemic state that would contribute to a higher risk of diabetes, and perhaps certain cancers (prostate, colon, breast). In this context, it is noteworthy that Snowdon has reported a prospective association between red meat intake and increased...

Studies Relating Very Low Meat Intake To Longevity

Fraser96 recently reported that, among Californian Seventh-Day Adventists, vegetarians were substantially more likely to have never smoked cigarettes or used alcohol, and to have no prevalent chronic disease. To account for potential confounding by these factors, ever-smokers, alcohol users, and subjects with history of coronary heart disease, stroke, and cancer were excluded from the previously unpublished analysis of Seventh-Day Adventists given in this chapter.

Wine and the heart is wine more cardioprotective than ethanol

The evidence summarized above demonstrates that light-to-moderate drinking is associated with a lower risk of coronary heart disease compared with non-drinkers, and that the protective effect appears to be genuine, independent of known biases and confounding factors. The evidence also suggests that heavy drinking does not provide protection against heart disease, and that it may, in fact, be associated with a higher risk compared with non-drinkers. The question remains whether, among moderate drinkers, wine is associated with a higher degree of protection against heart disease compared with other alcoholic beverages. This problem is addressed in this section. The hypothesis that wine protects against heart disease was originally proposed to explain the comparatively low mortality from coronary heart disease in France despite relatively high levels of known coronary risk factors, such as smoking, high blood pressure, cholesterol, fat intake or obesity (the 'French paradox'). One...

Chapter Summary continued

Tetralogy of Fallot is the most common cause of cyanotic heart disease and is characterized by a classic tetrad of pulmonary outflow obstruction stenosis, right ventricular hypertrophy, ventricular septal defect, and over-riding aorta. Carcinoid heart disease is a right-sided endocardial and valvular fibrosis secondary to exposure to serotonin in patients with carcinoid tumors that have metastasized to the liver.

AD Risk Factors and Retrogenesis

A broad variety of conditions which are known to be associated with either cerebrovascular or cardiovascular disease are now recognized as risk factors for AD. These include atherosclerosis per se 133 as well as indicators of cerebrovascular disease 134,135 . Cerebrovascular disease has also, in turn, been directly related to AD pathogenic elements and various well-recognized AD risk factors. For example, AD is now known to be characterized by cerebrovascular amyloid deposition, termed cerebral amyloid angiopathy (CAA) 136-138 . This CAA and related pathology have been considered to be of possible relevance in the etiopathogenesis of AD 136-141 . CAA involves intracortical arterioles and brain capillaries as well as the leptome-ninges. Almost all AD patients studied exhibit CAA. CAA has been related to trauma and anoxia, known risk factors for AD and dementia more generally. Foremost among these factors is the magnitude of amyloid- (A 6) deposition. Studies suggest that A 6 maybe the...

Exercises Lesson 2 Section I

A competent adult has a living will that specifies that she does not want extraordinary or heroic treatment (resuscitation) in the event that she should suffer a massive heart attack. She also has a Durable Power of Attorney for Health Care drawn up. Nine months later she has a heart attack and lapses into an irreversible coma. She is likely to be

Morbidity and Mortality Associated With Obesity

Many previous analyses, however, used older data sets obtained at a time when the screening and treatment of cardiovascular disease risk factors and diabetes were less aggressive than is currently the case. In a recent controversial analysis, Flegal et al. used NHANES data to make new estimates of excess deaths associated with underweight, overweight, and obesity (5). This analysis did not correct for the presence of comorbid conditions such as treated hypertension or treated hyperlipidemia. The results demonstrated that those with a BMI between 25 and 30 had a lower mortality rate than those with either a lower or higher BMI. Those with a BMI greater than 35 clearly had increased mortality. It appeared that the increased risk of mortality associated with obesity was higher in earlier cohorts, suggesting that current treatments for comorbid conditions may be improving the health of obese people. In a related study, Gregg et al. examined longitudinal trends in the management of...

Oxidative Phosphorylation

Patients with chest pain whose symptoms are suggestive of acute myocardial infarction (AMI) are evaluated by electrocardiogram (EKC) and by serial measurements of cardiac enzymes. Although myocardial specific CK-MB has been used as an early indicator of an AMI, measurements of troponin levels are rapidly replacing it. Troponin I and troponin T are sensitive and specific markers that appear three to six hours after the onset of symptoms, peak by 16 hours, and remain elevated for nearly a week. In the absence of ST-segment elevation on the EKC, elevated troponin I and troponin T are useful indicators of those patients at high risk for evolving myocardial infarction. LDH isozyme analysis may be helpful if a patient reports chest pain that occurred several days previously because this change (LDH, LDH2) peaks two to three days following an AMI.

The Menopausal Transition

Menopause signals the end of child-bearing capacity, and is also associated with changes in susceptibility to various chronic diseases, including breast cancer, heart disease, and osteoporosis.66 Differences in age at menopause between vegetarian and omnivorous women, should they exist, could be associated with differences in chronic disease patterns between these groups. Furthermore, some women experience unpleasant symptoms during menopause (vasomotor symptoms such as night sweats and hot flushes, mood swings, insomnia, weight gain, headaches, and fatigue),67 and these symptoms have been observed to differ among women in different cultures.67,68 Whether dietary variables contribute to these differences in symptom experiences has not been clearly established, but there is speculation that they could.68-70 Some of these dietary differences may also exist between vegetarian and omnivorous women. Accordingly, after defining and describing the menopausal transition, available research on...

Complications of Interventional Vascular Radiological Procedures

There are myriad systemic complications associated with angiographic procedures.Exam-ples include vasovagal syncope, cardiac arrest and arrhythmias, myocardial infarction, and nausea and vomiting. Contrast reactions can be reduced by adequate hydration and by using low osmolar contrast in high-risk patients. Rarely radiation injury in the form of a skin burn occurs when the procedure is lengthy and the patient is exposed to over 2 Gy.

Metformin and Sulfonylurea

Metformin sulfonylurea is the most popular combination and provides additive glucose-lowering and lipid-lowering effects, with metformin preventing weight gain and reducing triglyceride-cholesterol and LDL-cholesterol concentrations. This is particularly important because close to 80 of type 2 diabetic patients are overweight and almost all have some type of dyslipidemia. Metformin was the only oral agent shown to reduce myocardial infarction, stroke, and cardiovascular mortality in the UKPDS (7). A combination of metformin and glyburide (Glucovance) and metformin and glipizide (Metaglip) are currently available in the United States for glycemic control. These products provide a unique opportunity to begin combination therapy with one pill for patients with poorly controlled type 2 diabetes who have fasting blood glucoses greater than 200 mg dL or hemoglobin A1-C greater than 8 .

Protective effects of HDL

Epidemiological studies have generally shown a strong inverse correlation between plasma HDL concentration and incidence of coronary heart disease. The role of HDL in reverse-cholesterol transport is well established and many other protective effects against development of atherosclerosis have been reported (Barter & Rye, 1996). For example, HDL inhibits the oxidative modification of LDL inhibits the transmigration of monocytes induced by oxLDL blocks the induction by oxLDL of monocyte adhesion to the endothelium prevents oxLDL-induced cytotoxicity in vascular smooth muscle cells and endothelial cells removes cholesterol from cells in the arterial intima, thereby preventing the formation of foam cells ameliorates the abnormal vasoconstriction that is a feature of early atherosclerosis and stimulates prostacyclin synthesis and prolongs its half-life by binding to it.

Lipid Differences Between Omnivores And Vegetarian Or Vegans

The elderly vegetarian, particularly the elderly vegan, is in a protective life-style that minimizes ischemic damage, plaque formations, and lipid depositions involved in atherosclerotic disease, hypertension, stroke, or rheumatic heart disease. Plant dietary protein minimizes endogenous cholesterol and triacylglycerol production as previously discussed. Exogenous plant dietary fat supplies a dominance of unsaturated to saturated fatty acids to minimize not only the atherosclerotic diseases, but also several of the rheumatoid states, the mineral problems of osteoporosis, and possibly several types of cancer by the inclusion of polyunsaturated fatty acids (PUFA).3,40,41 This protective diet combined with adequate exercise inhibits the initiation of these diseases before they reach the lipid deposition stages by decreasing the initial free radical attack with antiox-idants. For example, in coronary artery disease (CAD), the vegetarian or vegan diet supplies the antioxidant vitamins and...

LDL cholesterol oxidation and atherosclerosis

The oxidative state of LDL is also affected by paraoxonase. Human serum paraoxonase (PON1) is an enzyme with esterase activity, which is physically associated with high-density lipoprotein (HDL), and is also distributed in tissues such as liver, kidney and intestine (La Du et al. 1993 Mackness et al. 1996). HDL-associated PON1 has recently been shown to protect LDL, as well as HDL particles, against oxidation induced by either copper ions or by free radical generators (Aviram et al. 1998 a,b). This effect of PON1 may be relevant to its beneficial properties against cardiovascular disease (Aviram 1999 La Du et al. 1999), since human serum paraoxonase activity has been shown to be inversely related to the risk of cardiovascular disease (Aviram 1999 La Du et al. 1999). On the other hand, PON1 was found to be inactivated by lipid peroxides, and antioxidants were shown to preserve PON1's activity because they decrease the formation of lipid peroxides (Aviram et al. 1999).

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