Hospital Chronicles (E-Journal)
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Health Hazards From Trans Fatty Acids: Ban of Artificial Trans Fats Long Overdue
Get PDF Although we are all abundantly aware of the health risk of saturated fat, not much attention and proper warning is given to the even more hazardous effects of unsaturated trans fatty acids. Trans fatty acids (TFA) are created by the partial hydrogenation of vegetable oils, a process converting them into semisolid fats for use in margarines, commercial cooking, and manufacturing processes, as they offer certain commercial advantages. However, major concern has been raised for TFA as they are associated with an elevated risk of ischemic heart disease (IHD). Trans fat behaves similar to saturated fat by raising LDL levels, but furthermore, it has the additional effect of decreasing HDL levels. Health authorities should advise the public to minimize the intake of trans fats, to recognize and avoid foods containing trans fats, and impose rules and regulations restricting TFA in the industry and the restaurants and thus prevent thousands of IHD events each year worldwide
Handling Pain in the Coronary Care Unit
Get PDFPain is not only a symptom for warning a person for a health problem. The mechanism of pain increases the cardiac load, increases the needs of myocardium and other tissues in oxygen, thus increasing myocardial ischemia. This results in instability of patient’s hemodynamics andprobable failure of treatment’s implementation. Therefore, the relationship between pain and cardiac disease is interactive: cardiac patient feels pain because of the underlying heart disease, and the disease is worsening because of pain. As health professionals, we must concentrate on patient’s comfort and relief. Even within the difficult working conditions of the cardiac care unit (CCU), the patient in pain should be approached with compassion and care. We should not forget that pain is the usual symptom which leads the patient in search for health services and then to the CCU. The development of a trust relationship between the health professional and the patient is the basis for the expression of pain and fears by the patient. Physical examination helps refine the differential diagnosis. Delay in treatment can lead to a substantial recidivism of the disease. The patient should be constantly encouraged to alert the personnel of any complaints of pain. The evaluation of pain through the dialogue and the clinical evaluation individualizes treatment. Administration of analgesics, tranquillizers and sedative medicines contribute to the reduction of patient’s agony and stress and help him or her to control factors causing pain. Within a multidisciplinary group, nursing personnel have a unique, important and independent role in handling pain in the CCU
Problems Arising From the Prolonged Use of Aspirin and Clopidogrel Imposed by Drug-Eluting Stents / Conundrums in Triple Antithrombotic Therapy: Newer Suggestions
Get PDFDual antiplatelet therapy (DAT) can decrease effectively the rate of major adverse cardiovascular events after drug-eluting stent (DES) implantation in high-risk coronary artery disease (CAD) patients, but its implementation is associated with excess in bleeding events compared with aspirin monotherapy and a considerable treatment failure rate, namely persistence of occurrence of ischemic events, despite the use of the recommended dosage of the standard DAT. All large-scale antiplatelet randomized controlled trials have shown that the prolonged administration of DAT after coronary stenting provides improved thrombotic prevention at a cost of increased bleedings. Newer antiplatelet regimens including higher maintenance doses of clopidogrel, or using the newer agents, prasugrel or ticagrelor, can effectively reduce rates of myocardial infarction and stent thrombosis during follow-up of high-risk CAD patients undergoing an invasive therapy, but they are accompanied by an increase in bleeding rates and, except for ticagrelor plus aspirin, do not reduce mortality. Therefore, the challenge remains to develop therapies that more effectively inhibit platelet activation and have a beneficial net effect on mortality without increasing bleeding complications. For patients receiving triple therapy, they are advised to keep the dose of aspirin as low as possible (75 to 81 mg); clopidogrel should be given at its standard dose of 75 mg/day, and warfarin should be administered under tight control to achieve a slightly lower target INR of 2.0 to 2.5. It is also suggested that proton-pump inhibitors (PPIs) should be considered as prophylaxis against gastric bleeds, tending to use pantoprazole and esomeprazole, which have the least incriminating data regarding an interaction with clopidogrel. In patients with mild or moderate bleeding while on triple therapy, every effort should be made to maintain the INR as close to 2.0 as possible, and the aspirin dose should be kept at < 100 mg. If bleeding persists, it is advised that aspirin be discontinued first, as clopidogrel seems to be more important than aspirin in preventing stent thrombosis after PCI
NonPharmacologic Management of Atrial Fibrillation Using the Dynamic Atrial Overdrive Algorithm
Get PDFA concomitant condition found in many patients with atrial fibrillation (AF) commonly requires bradycardia pacing. Comparing AAI to VVI pacing, atrial pacing appears to have an apparent protective effect on the subsequent development of AF. By addressing the proposed mechanisms responsible for AF (long-short cycles, increased temporal dispersion of refractoriness, frequent atrial ectopic beats), overdrive appears to be a promising technique to postpone or even prevent entirely the development of chronic AF while reducing the incidence of paroxysmal AF. These observations led to the development of a pacing algorithm (Dynamic Atrial Overdrive-DAO) designed to provide a high percentage of atrial pacing just above the patient's own intrinsic atrial rate. The algorithm is a dynamic stimulation technique to suppress AF effectively, overdrives the atrium just enough to prevent the intrinsic rhythm from emerging while maintaining both normal diurnal variation and rate response. Dynamic Atrial Overdrive is a unique pacemaker algorithm designed specifically for suppression of paroxysmal AF arising from either an absolute or relative bradycardia. By maintaining an atrial stimulation rate just above the intrinsic rate, the goal is to control both the atrial rate and rhythm, reducing the incidence of ectopic beats which might be a trigger, long-short cycles, or the dispersion of refractoriness from initiating AF. In addition, because the algorithm routinely searches for intrinsic atrial activity and adjusts the stimulation rate accordingly, it avoids sustained periods of rapid stimulation that may not be required. At the same time, it preserves the normal circadian rate variation in association with normal sinus function or in the presence of sinus node dysfunction if the sleep rate feature is also enabled
Is Detection of Hibernation Critical in Deciding Surgical Revascularization in Patients with Very Low Ejection Fraction?
Get PDFMyocardial hibernation denotes chronic ventricular dysfunction, regional and/or global, due to myocardial ischemia usually due to ischemic heart disease. A postulated mechanism may be relayed to subacute or chronic myocardial ischemia resulting from a reduction of coronary blood flow. Techniques to detect and quantitate the extent of viable myocardium may include nuclear imaging and 18-fluorodeoxyglucose positron emission tomography (FDG PET). When a sufficient amount of viable myocardium is present, surgical or percutaneous revascularization appears to be effective in relieving symptoms and improving left ventricular function and prognosis even in patients with a very low ejection fraction. Thus, detection of viable hibernating myocardium is highly desirable before revascularization is undertaken
Coronary Artery Disease, Nicotine Addiction, and Depression: The Tragic Triad
Get PDFA great number of diseases are directly related to active smoking. In the recent years more and more malignant neoplasms were causally related to active smoking. Lung cancer is the “leader” of smoking-related neoplasm’s and the 3rd cause of death in high-income countries, followed by cancer of the oral cavity/pharynx, laryngeal, esophageal, stomach, pancreatic, kidney, bladder, cervical cancer, leukemia and othermalignant neoplasm’s. Among other diseases, cardiovascular and respiratory diseases are also causally related to cigarette smoking. According to World Health Organization (WHO), 5 out of 6 leading causes of death world wide (Ischemic heart disease, cerebrovascular disease, HIV/AIDS, COPD, lower respiratory infections trachea, bronchus, lung cancers) are smoke related... (excerpt
Bare Metal Stents Versus Drug Eluting Stents - How do we Choose?
Get PDFPercutaneous coronary intervention (PCI) with stent placement has been proven a very effective way to treat patients with significant coronary artery disease (CAD) with acute and chronic clinical coronary syndromes. Over the last 8 years drug-eluting stent (DES) use has surpassed bare metal stent (BMS) use, mainly because DES reduce significantly the in-stent restenosis and decrease future major adverse cardiac events. The use of DES has expanded the application of PCI to more complex CAD patients. The only major, infrequent but critically important, problem with at least the firstgeneration DES use is the late stent thrombosis and the required long term dual antiplatelet treatment, which is probably due to endothelial dysfunction.... (excerpt
European Lung Cancer Working Party Clinical Practice Guidelines. Non-small cell lung cancer: I. Early stages
Get PDFThe present guidelines on the management of resectable non-small cell lung cancer (NSCLC) were formulated by the (ELCWP) in April 2005. They aim in answering the following eleven questions: 1) Is surgery the best therapy for a potentially resectable cancer? 2) How is complete resection defined? 3) Is systematic lymph node dissection necessary during surgery? 4) What is the role of radiotherapy after complete resec tion? 5) Should adjuvant or neoadjuvant chemotherapy be administered in clinical stages I or II? 6) Should adjuvant chemotherapy be administered in pathological stages I or II? 7) Is adjuvant therapy advisable after complete resection for pathologi cal stage IIIA N2? If yes, of what type: chemotherapy, radiotherapy or chemotradio herapy? 8) What are the indications for surgery after induction treatment, in clinical stages IIIA or IIIB? 9) In clinical stages IIIA or IIIB, is preoperative therapy required and of what type? 10) What type of treatment is indicated after an incomplete surgical resection? 11) What is the best regimen for (neo)adjuvant chemotherapy
Pseudo Left Main Coronary Artery Disease
Get PDFA 72-year-old hypercholesterolemic gentleman with anginal symptoms Canadian Cardiovascular Society (CCS) class III and a positive thallium scintigraphy with ischemia localized to the anterior wall, was submitted to coronary angiography. Initial images indicated a distal left main coronary artery stenosis (left upper panel, large arrow). However, subsequent views pointed to a ???phantom?? artery imaged belatedly (right upper panel, short arrow). It was only after a tedious exercise that successful engagement of a separate ostium of another left coronary artery clarified the anatomy of this patient (left lower panel). It thus became apparent that it was a separately originating, diseased left anterior coronary artery descending (LAD) which explained the localization of this patient???s ischemia to the anterior wall. This was finally remedied with successful direct stenting of the long stenotic segment of the LAD performed during the same session (right lower panel), thus obviating emergency coronary artery bypass grafting, which would have been a plausible course of action, should one have relied upon the initial imaging perfectly mimicking a left main disease
Will Stents of New Technology Replace Coronary Artery Bypass Surgery?
Get PDFCoronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are commonly used procedures to treat patients with multi-vessel coronary artery disease requiring myocardial revascularization. In the past, several randomized comparisons between bypass surgery and coronary angioplasty were performed but had the limitation of comparing CABG to balloon angioplasty.These studies, performed in the pre-stent era, showed no significant differences in mortality and nonfatal myocardial infarction between patients treated with surgery versus PCI. Surgery had an advantage only in treated diabetic patients. More recently, in the stent era, new randomized comparisons between PCI and bypass surgery have been performed. The long-term follow-up data of the four randomized trials of PCI using bare metal stents versus CABG (Stent or Surgery trial, Artery Revascularization Therapies Study [ARTS], ERACI II, and Medicine, Angioplasty, or Surgery Study [MASS] II) showed similar incidence in the combined death, non-fatal myocardial infarction, and stroke rate with both revascularization techniques. However, contemporary treatment of coronary artery disease with stents has switched to the use of drug eluting stents. In a manner similar to the impact of bare-metal stents compared with non-stent balloon angioplasty, drug-eluting stents further reduce restenosis. Data from ARTS II support further reduction in need for repeat interventions in the stent group. During the time since these studies were initiated, CABG procedures have undergone also progressive improvement. The effects of PCI with drug-eluting stents versus minimally invasive direct coronary artery bypass surgery in the management of patients with proximal left anterior descending coronary artery stenosis were recently reported and drug-eluting stent implantation resulted in lower average number of hospital stays and similar postoperative complications. Ongoing trials should further clarify the divergent information streams in this comparison