Hospital Chronicles (E-Journal)
Not a member yet
657 research outputs found
Sort by
The Role of Double Renin-Angiotensin System Blockade
Get PDFBlockade of the renin-angiotensin system (RAS) is now recognized as an effective means of lowering blood pressure and protecting hypertensive patients from end-organ damage. There are three pharmacologic approaches to blockade of the RAS, with angiotensin-converting enzyme (ACE) inhibitors, with angiotensin II receptor blockers (ARBs), and with direct renin inhibitors. Clinical studies with the first two classes have shown that neither one achieves complete blockade of the RAS. However, an almost complete blockade of the RAS can be achieved by combination of an ACE inhibitor plus an ARB, albeit not with consistent benefits. A complete blockade of the RAS can also be obtained by combination of an ARB with a renin inhibitor. Further outcome trials are needed to show which combination offers long-term advantages in terms of end-organ protection
Selective Inhibition of Cardiac Pacemaker (If) Current: the Role of Ivabradine in the Treatment of Angina
Get PDFHeart rate reduction plays a pivotal role in the management of myocardial ischemia and chronic stable angina. Rate-slowing drugs, such as beta-blockers are considered the cornerstone of antianginal therapy. However, the broad use of beta-blockers is limited by their side-effects. Ivabradine is the representative of a new class of agents that exclusively reduce heart rate through inhibition of the sinoatrial pacemaker (If) current. Ivabradine reduces cardiac heart rate in doses that do not affect other ionic currents, resulting in a decrease in cardiac oxygen consumption and in an increase in diastolic period. Ivabradine has no negative inotropic or lusitropic effects, and does not change any major electrophysiological parameter. Large randomized trials have provided evidence for its efficacy in stable angina and have demonstrated anti-ischemic properties similar to atenolol and amlodipine. Moreover, ivabradine provides an attractive alternative to conventional therapy, whenever use of beta-blockers or calcium-channel blockers is contraindicated. Treatment of sinus tachyarrhythmias is another area where the use of ivabradine seems promising. Ongoing trials with ivabradine will determine its effect on mortality and morbidity in patients with coronary artery disease and left ventricular dysfunction
Cardiac Resynchronization Therapy - How to Overcome High Left Ventricular Pacing Thresholds and Avoid Phrenic Nerve Stimulation
Get PDFHigh pacing thresholds and phrenic nerve stimulation (PNS) are not uncommon in contemporary cardiac resynchronization therapy (CRT) systems, based on our own experience as well as on other series. Whereas some cases may be resolved by programming, other cases necessitate reoperations or abandonment of the left ventricular (LV) lead. Approaches to avoid and to manage these two problems are reviewed according to our experience as divided into four phases: 1) During implantation ??? whereby careful selection of pacing site is required, as well as meticulous testing of thresholds and PNS, and avoidance of any site with any PNS; 2) Device and lead selection ??? in difficult cases with high thresholds and PNS, a system with multiprogrammable pacing configurations and bipolar leads may be preferred; 3)Programming ??? we found a significant advantage of systems with multiprogrammable pacing configurations and bipolar leads in dealing with PNS and high thresholds with essentially nearly 100% of those problems being resolved by reprogramming the pacing configuration in the LV lead; 4) Epicardial implantation ??? in cases where adequate LV pacing cannot be achieved, epicardial pacing should be considered with special emphasis on appropriate lead location
Multivessel Coronary Angioplasty with Drug Eluting Stents in a Chronically Hemodialyzed Diabetic Patient with Impaired Left Ventricular Systolic Function
Get PDFWe present a case of staged multivessel percutaneous coronary intervention (PCI) with drug-eluting-stents (DES) in a diabetic patient with three-vessel coronary heart disease (CHD), dialysis-dependent chronic renal failure and impaired left ventricular (LV) systolic function. The optimal method of coronary revascularization in dialysis patients is controversial. Surgical treatment (CABG) is a high-risk procedure. CABG in the pre- DES era was associated with a better long-term prognosis, but at the cost of higher in-hospital mortality. PCI using DES may be a feasible therapeutic alternative.The revascularization strategy is reviewed
The Emerging Role of Inflammation and Fibrosis in Atrial Fibrillation and the Potential of Counter Interventions
Get PDFAtrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice, affecting approximately 0.9% of the population. The prevalence of AF is strongly age-dependent, affecting approximately 1% of persons aged 65 years and 5% of individuals older than 65 years.2 AF is also associated with an increase in the relative risk of mortality ranging from 1.3 to 2.34, independent of other risk factors as well as an increasing morbidity and adversely affects quality of life.3-5 Unfortunately, current rhythm control strategies are far from ideal. Data from five comparative studies of a primary rate control vs. rhythm control strategy for patients with a history of AF failed to show a significant superiority of rhythm control. In fact, these studies merely emphasized the limited efficacy and high side-effect profile of the currently available anti-arrhythmic drugs
Classical and Non-Classical Indications for Cardiac Resynchronization Therapy
Get PDFHeart failure (HF) is a medical problem of huge socioeconomic importance, mainly due to the increasing life expectancy in our societies and the strides in the treatment of ischemic heart disease which resulted in improved prognosis of our patients. These medical and socioeconomic issues may explain why HF poses a significant financial burden on our health care systems. It is estimated that acute decompensated HF accounts for 2.9% of all emergency room visits, its prevalence is steadily increasing in epidemic proportions and in age-dependent manner, reaching an incidence of almost 10% in patients aged >65 years
Closure of Atrial Septal Defect and Patent Foramen Ovale, the Simple Way
Get PDFCatheter based closure of atrial septal defects was first described in 1974 but has only been used widely since the nineties. In 1992 the focus turned to closure of the patentforamen ovale which today is the most common atrial shunt closure. While the majority of centers advocate use of transesophageal or intracardiac echocardiographic guidance during implantation, fluoroscopy guided implantation is feasible, faster, cheaper, and more patient-friendly. Closure of a patent foramen ovale with an Amplatzer occluder (currently the preferred device) may take as little as 10 minutes with the possibility to return to full physical activity a couple of hours later. Complications are exceedingly rare (<1%). They include (about in the order of frequency) inguinal access problems, thrombus on the device, device embolization, cardiac perforation, erosion of the atrial wall by the device, or infection of the device. So far there are no reports of late complications although atrial fibrillation is one to be looked out for
European Lung Cancer Working Party Clinical Practice Guidelines. Small Cell Lung Cnacer: IV. Limited disease
Get PDFThe present guidelines on the management of limited disease small cell lung cancer (SCLC) were formulated by the ELCWP in April 2007. They are designed to answer the following seven questions: 1) What is the definition of limited disease? 2) Should chest radiotherapy be provided and what are the benefits? 3) What is the optimal timing and mode of administration of chest irradiation? 4) Which are the optimal radiotherapy parameters: dose, fractionation, target volume? 5) What is the optimal chemotherapy regimen for limited disease SCLC? 6) Should prophylactic cranial irradiation be provided, when and for which patients? 7) What is the additional role of thoracic surgery in early SCLC
Primary Percutaneous Coronary Intervention in Acute ST-Elevation Myocardial Infarction: The Experience of "Evagelismos" General Hospital of Athens
Get PDFWe report our experience from treating a large number of patients who presented to the Emergency Department of our Hospital with ST-elevation acute myocardial infarction (AMI) with primary percutaneous coronary intervention (PCI). Of the 196 patients who presented with ST elevation AMI over a period of 12 months, 100 (51%) patients underwent primary PCI. Clinical and angiographic data were collected and patients were followed up for 9 months. Technical details of the primary PCI, including use of balloon, use of thrombus aspiration catheter, stent implantation, use of drug eluting stents, and use of GP IIb/IIIa inhibitors were recorded and correlated to clinical and angiographic patient data. Our results are in keeping with those published by other groups performing primary PCI. We demonstrated the importance of time interval from onset of symptoms until PCI is started. We found that the use of GP IIb/IIIa inhibitors was beneficial and emphasized the predictive value of left ventricular ejection fraction >50% and the importance of achieving TIMI 3 flow in the AMI related artery at the end of the procedure
Cryptogenic Stroke and Migraine Headache: The Clinical Cardiologist's View
Get PDFCryptogenic stroke and migraine headache are disorders which most commonly affect persons younger than 55 years of age. In recent years these disorders have been found to have a strong association with inter-atrial cardiac defects, such as patent foramen ovale and atrial septal defect, and support the pathophysiological mechanism of paradoxical embolism with a right-to-left shunt. With the evolution of technology, magnetic resonance imaging has more clearly defined cryptogenic stroke, and percutaneous cardiac interventional devices have offered a simplified approach to closure of inter-atrial cardiac defects. Nevertheless, the evidence-based data of which sub-populations of patients with cryptogenic stroke or migraine headache will benefit from closure of inter-atrial cardiac defects is just being defined. This review offers a clinical cardiologist???s viewpoint of these developments