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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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...

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

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 takeh-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...

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).

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...

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

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

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...

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.

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

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.

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.

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...

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< 0.02). This is in agreement with the few data available on the consequence of coronary artery disease on the adaptation of the left ventricle to aortic stenosis. Patients with aortic stenosis and coronary artery disease have a higher systolic wall stress because of a less pronounced hypertrophy than patients with aortic stenosis and normal coronary arteries24,25. The negative effects of hypertrophy on left...

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...

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...

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.

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.

Differential Diagnosis of ST Elevation

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.

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...

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...

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.

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.

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.

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,...

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

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...


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.


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).

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...

ST Elevation

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,

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.

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...

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.

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.

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...


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.


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.


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...

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...

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.

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.


When Robert Freuhauf was admitted to the coronary care unit, you learned during your nursing evaluation that Robert was unfortunate enough to have had a myocardial infarction seven years previously at the age of 33. Robert had a cardiac catheterization shortly thereafter, the results of which are unclear to you. He can only remember that they told him he had a tear in a vessel wall. After 7years free of chest pain, or other symptoms, Robert had been readmitted 2 weeks ago with a several week history of exertional chest discomfort relieved by rest, and then, finally, an episode of pain at rest, leading to admission. After several days in the CCU, Robert had had a treadmill stress test performed, which was negative, and he was discharged on aspirin and simvastatin. c) inferior myocardial infarction that may be old. d) anterior myocardial infarction that may be old. f) LBBB simulating anterior myocardial infarction. c) inferior myocardial infarction that may be old. d) anterior...

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...

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

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...

Regular physical activity

Moderate levels of physical activity have significant effects on a woman's health. Burning approximately 150 kilocalories per day or 1000 kilocalories per week leads to a reduction in the risk of coronary heart disease by 50 and of hypertension, diabetes, and colon cancer by 30 .2 After adjusting for covariates such as age, smoking, alcohol use, history of hypertension, and history of high cholesterol, women who are regularly physically active are 50 less likely to develop type II diabetes (relative risk 0.54) than women who are not regularly active.8 Vasomotor and psychosomatic symptoms associated with menopause are also reduced with moderate amounts of activity.6,9 Examples of moderate levels of physical activity are depicted in Table 2.2.

Mouse Human Differences

From a medical perspective, the disease processes in the mouse are likely to be different. First of all, the mouse progresses rapidly through development and has a short life span. Therefore, diseases that emerge during a specific developmental stage have only a short window of opportunity. Also, with a life span of only 2 years, mice will age rapidly, and chronic human diseases only have months to develop in a mouse. An example is the absence of tumors in mice heterozygous for a mutation in the retinoblastoma gene, which is a tumor supressor gene in humans (see Chapter 17). However, in general, the short time frame is not a major problem in mouse studies on cancer and neurodegenerative and cardiovascular disease. Second, the physiologic properties of a mouse are tuned to its small size. With an average weight of only 40 g, its is clear that many diseases will have a completely different course in a mouse, when size and body mass are important. For example, a mutation in the...

Tropical Infectious Diseases

Globally, as assessed in terms of disability-adjusted life years (DALYs), which measures morbidity and mortality,111 infectious diseases in 1990 accounted for 36.4 of total DALYs. Infectious disease DALYs were considerably in excess of those attributable to cancer (5.9 ), heart disease (3.1 ), cerebrovascular disease (3.2 ), or chronic lung disease (3.5 ).116

Alternative therapies

After maximal exercise, and reduces heart rate and left-ventricular end-diastolic volume at rest.39,40 Similar benefits would be expected for women however, there is a paucity of research dealing with women. Additionally, yoga practice may retard the progression and increase the regression of atherosclerosis in patients with coronary artery disease.41 T'ai chi practice improves mood states, range of motion, physical function, and hemodynamic parameters.32,42,43 Reductions in anger, total mood disturbance, tension, confusion, and depression and an increase in self-efficacy are evident after regular t'ai chi practice.32 Improvements in self-reported physical function and a reduction in falls is also reported.37,42,44 Patients suffering from acute myocardial infarction can reduce blood pressure after practicing t'ai chi.45 T'ai chi is an effective modality for improving several aspects of health. Empirical scientific evidence has demonstrated the positive benefits of exercise, such as...

Arteriovenous Fistula

Discussion Oxygenated blood from the left atrium passes into the right atrium, increasing right ventricular output and pulmonary flow. Acyanotic (left-to-right shunt) the most common congenital heart disease in adults. Sequelae of untreated atrial septal defects include paradoxic emboli, infective endocarditis, and congcstivc heart failure.

Abdominal Aortic Aneurysm

A 59-year-old man presented with an abdominal aortic aneurysm (AAA) discovered on duplex scan examination of the abdomen. The AAA was 60-mm large and extended to the left common iliac artery. The patient was otherwise asymptomatic, with no abdominal or back pain. His medical history was significant for hypertension controlled by bitherapy, non-insulin-dependent diabetes diagnosed 5 years previously, claudication with a walking distance of 400 metres, and a smoking history of 40 packs year. He had no history of myocardial infarction (MI) or angina pectoris.

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 < 96 mg dl (2.5 mmol l) 5 and National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III 13 LDL-C target < 100 mg dl (2.6 mmol l) have been revised recently. Thus, the UK guidelines set the LDL-C goal to < 2.0 mmol l (77 mg dl) for high-risk patients (March 2004) 37 . Furthermore, the revised NCEP ATP III guidelines proposed the optional target of < 70 mg dl...

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.

Weight concerns Overweight and obesity

Strong evidence supports an association between obesity and increased morbidity and mortality. Recent research has linked excessive weight and body fat to a dysmetabolic syndrome, which includes diabetes, hypertension, and coronary artery disease.11 The Atkins Diet is a restricted-carbohydrate, high-protein, and restricted-fat diet. This diet takes advantage of the ketosis that develops during starvation the resulting anorexia reduces appetite. However, ketosis can also cause fatigue, constipation, and vomiting. Potential long-term side effects include heart disease, bone loss, and kidney damage. In addition, high-protein, low-carbohydrate diets tend to be low in calcium, fiber, and healthy phyto-chemicals. The proponents of this diet advise taking vitamin and mineral supplements to replace lost nutrients. The Pritikin Diet is a very-low-fat (15 of calories), high-fiber, vegetarian (or nearly vegetarian) diet combined with exercise. It claims to reduce serum cholesterol and prevent or...

High Density Lipoprotein HDL

High-density lipoproteins (HDL) are plasma proteins that function as carriers of plasma cholesterol. Measuring the cholesterol contained in the HDL molecule is predictive of the individual's risk for coronary artery disease. It is believed that the HDL molecule carries cholesterol from the peripheral tissues of the body to the liver, where the cholesterol is converted into bile

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.

Risk And Protection Factors For Dementia

If the causes of dementia in the elderly were understood, it would be possible to use this knowledge to develop preventive strategies. However, even in the absence of a full understanding of its causes, it is possible to base prevention around factors known to increase or decrease the risk of developing dementia. Some risk and protection factors cannot be easily modified and so provide no basis for preventive action. For example, we might know that a family history of dementia increases risk for AD, but there is nothing we can do to modify this risk, at least so far. Gene therapy for dementia remains a distant prospect. Some other factors are modifiable and it is these that are important for prevention. This strategy is already used to prevent other common health problems such as cancer and heart disease.

Evaluation Of The Severity Of Mr

Obviously, patients should not undergo valve surgery unless there is severe regurgitation. Non-invasive imaging can provide all the information needed to gauge the severity of MR left and right ventricular function, the cause and severity of MR, the presence of pulmonary hypertension and associated valve lesions as tricuspid regurgitation and aortic valve disease Cardiac catheterisation with exercise hemodynamics and angiography is only indicated when there is discrepancy between clinical and non-invasive findings. Although ventriculography has its own limitations11, it provides an additional method to assess chamber dilation and function and to estimate MR severity. Right heart catheterisation is only indicated when there is uncertainty about MR severity and pulmonary hypertension. Coronary angiography is indicated in patients with risk factors for coronary artery disease including age, hypercholesterolemia, and hypertension.

Developmental issues for the midlife woman

Women in the USA are presented with two predominantly negative scripts of the mid-life experience. One script is of a medicalized focus on menopause as a time of transition from a healthy, estrogen-rich time of life to the stage of inevitable health decline, with an attendant increased risk of heart disease and osteoporosis. The other readily available scenarios are social descriptions of an empty nest, abandonment for the woman, or that of a useless, used-up fertility has-been.1 Both of these views are in contrast with the repeated observations that women feel better about menopause, and themselves, after having traversed it.2,3 Considerable sociocultural variation in attitude toward the experience of menopause exists.4,5 Yet, overall, women have positive associations with mid life as a time to take stock and renew. Primary care providers have the opportunity to explore these beliefs with their patients and educate them about what is actually known about wellbeing during mid life.

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...

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...

Aspartate Aminotransferase AST Serum Glutamic Oxaloacetic Transaminase SGOT

Increases in AST SGOT levels are most often associated with myocardial infarction and various liver diseases. In myocardial infarction, the level may increase from 4 to 10 times the normal amount, while liver disease may display levels of 10 to 100 times the normal range. Acute and chronic hepatitis, primary or metastatic liver cancer, alcoholic hepatitis, and Reye's syndrome produce increased AST levels.

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.

Useful Additional Therapeutic Strategies

PTCA or CABG should only be performed in patients who meet the criteria for the respective procedures independent of the proposed vascular surgery. The benefit of prophylactic coronary revascularization has never been proven in a randomized controlled trial (RCT) however, several retrospective studies have shown that patients who have undergone CABG have the same morbidity and mortality from cardiac complications as those with no clinical signs of coronary artery disease 3 .

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.

C Avoiding Risk of Any Counter Therapeutic Harm Whatsoever The way

That therapeutic privilege is applied varies across legal jurisdictions. Some courts permit physicians to withhold information if disclosure would cause any counter therapeutic deterioration whatsoever (be it physical, psychological, or emotional). For example, if the physician has a patient with a weak heart, should the physician risk a possible heart attack by telling the patient about a suspected cancer The physician may decide to withhold this information, or may opt to announce it with carefully chosen words I see a growth that I'm concerned about. We need to do a biopsy to check it out.

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).

Misuse Of Therapeutic Privilege A Hypothetical Case

Risk of Jeopardizing Success of Treatment or Impairing Decision -Making Abilities. In some jurisdictions, the physician can withhold information if, and only if, the patient's knowledge of the information would have serious health-related consequences,for example, jeopardizing the success of treatment or critically impairing relevant decision-making processes through psychological harm. In the example cited above, if the physician thought that revealing the suspected cancer would result in a heart attack, he or she might exercise therapeutic privilege. If there will be pain associated with the proposed procedure, the physician must still disclose that information to the patient, even though it might complicate or hinder treatment. The patient can demand to know more about the pain and discomfort before giving consent. In such a situation, some physicians, who simply wish to avoid the nuisance of an emotional scene with the patient, may choose to exercise therapeutic privilege and...

Plasminogen Activator Inhibitor1

Plasminogen activator inhibitor (PAI)-1 is released by adipocytes, as well as other adipose tissue constituents, with visceral fat contributing higher amounts compared to subcutaneous depots (81). This adipokine acts as an inhibitor of fibrinolysis and proteinolysis (118), thereby helping to maintain vascular homeostasis. Higher levels of this protein promote increased susceptibility to clotting, a critical event in the pathogenesis of such conditions as myocardial infarction and stroke. Its release is also induced by the proinflammatory cytokine TNF-a (119). The primary role of PAI-1 is to help maintain vascular homeostasis (127). This protein is actually implicated in the pathogenesis of cardiovascular disease, with plasma levels being a strong predictor of future cardiovascular disease development (128). It will be interesting to follow the results of future studies when it might be determined how PAI-1 contributes to obesity-related pathologies.

Telling The Next Of

A pregnant woman with an inordinate fear of surgery and a history of heart problems goes into labor. As the labor progresses, it becomes increasingly apparent that the baby, who in the breech position, will have to be delivered by Caesarean section. In view of the woman's weak heart and expressed fear of being operated on, the physician decides to exercise therapeutic privilege, withholding the fact that the baby will have to be delivered by C-section. The husband is informed that delivery will be by C-section and his consent is duly obtained. This possibility had been discussed by the physician and the woman's spouse prior to delivery. Risks and benefits of a Caesarean delivery had been covered with the spouse earlier and his permission had been obtained at that time.

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 .

And Endovascular Surgery

Patients treated for aneurysmal disease with stent graft usually have a much easier recovery and fewer postoperative complications than those treated with open repair. Thus the need for peri- and postoperative monitoring is less extensive in these patients. There are fewer cardiac complications both peri- and postoperatively when comparing patients with the same degree of preoperative heart disease. This is probably due to the much smaller total surgical trauma, but in particular the fact that aortic cross clamping is not needed during the procedure. However, patients not fit for conventional surgical aortic aneurysm repair due to a combination of co-morbid conditions are now receiving aortic stent graft treatment, and these patients are at increased risk of postoperative complications 15 . The level of postoperative monitoring will naturally reflect the patient's preoperative condition and possible adverse events during stent grafting.

Longterm complications of diabetes

Diabetes mellitus is a long-term disorder associated with a number of clinical problems causing ill health and death. Disease affecting the small blood vessels in the retina, kidney, and peripheral nerves appears to be most directly related to the duration and severity of the raised blood glucose (hyperglycemia). These complications are termed microvascular and may result in blindness, chronic renal failure requiring dialysis, and nerve damage to the feet contributing to the formation of foot deformity and ulceration. Large blood vessels are also affected (macrovascular disease) in the heart, brain, and peripheral circulation. People with diabetes have higher rates of coronary heart disease,4849 stroke,50 and peripheral vascular disease51 compared to similar subjects of the same age and sex. This contributes significantly to the higher rates of ill health and early death in people with diabetes.

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 ).

Beneficial effects of alcohol consumption

Before the age of 60, breast cancer is a more important cause of death than heart disease. Later on, the risk of heart disease exceeds that of breast cancer, so the benefits of moderate drinking are more apparent. The consumption of at least one drink a day by mid-life and elderly women is associated with a 20 reduction in the risk of cardiovascular disease compared with non-drinkers.38 Like men, women appear to experience a U-shaped relationship between alcohol consumption and coronary artery disease.

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...

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