Hospital Chronicles (E-Journal)
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Clinical Utility of Cardiovascular Magnetic Resonance Imaging for Diagnosis of Acute Myocarditis
Get PDFA 49 year-old patient with past medical history significant for arterial hypertension (treated with telmisartan 80 mg daily), presented to the emergency department with 18-hour gastric discomfort and fatigue. Five days prior to this presentation the patient had an episode of febrile gastroenteritis. The evening prior to presentation the patient had blood chemistries performed at an outside institution, where an increase of myocardial enzymes (troponin and CPK-MB) were noted. On presentation the patient was uncomfortable due to abdominal pain, but the clinical examination was almost normal. Blood pressure was 150/80 mmHg and heart rate was 60 beats/min. Cardiac S1 and S2 sounds where audible, without additional cardiac tones, murmurs, pericardial or pleural friction. There was no jugular venous distention, rales or peripheral edema present. Admission 12-lead electrocardiogram (ECG) demonstrated normal sinus rhythm with a rate of 60 beats/min, and early repolarization pattern with a slight J-point elevation in the lateral leads (I, aVL, V5, V6)
Current Guidelines for Hypertension: Important Highlights for Clinical Practice
Get PDFIn 2007 the European Society of Hypertension, the American Heart Association and the International Society of Hypertension-World Health Organization published new guidelines for the management of hypertension. The need of developing new guidelines for hypertension is due to recently published research data suggesting important modifications in the diagnostic and therapeutic strategies in clinical practice.The implementation of the new guidelines is expected to achieve more effective cardiovascular protection in hypertensive patients
The Impact of Reducing Hypertensive Left Ventricular Hypertrophy on Sudden Cardiac Death
Get PDFIt has been well recognized that the presence of left ventricular hypertrophy (LVH) is an adverse feature in hypertension, with such patients having a substantially higher risk of cardiovascular events, including mortality and morbidity from heart failure, ventricular arrhythmias, death from myocardial infarction, sudden cardiac death and cerebrovascular episodes. ECG may show findings suggestive of hypertrophy but echocardiography is the preferred test for the evaluation of the presence and extent of hypertrophy. The reduction of blood pressure via life style interventions and with the use of antihypertensive agents reduces cardiac mass in patients with LVH. This reduction is related both to the degree of antihypertensive response and to the specific therapy used. It appears that the degree of regression is more pronounced with angiotensin-converting enzyme inhibitors and calcium channel blockers, especially non-dihydropyridines. The regression of LVH is accompanied by a reduction in sudden death, acute myocardial infarction and heart failure
Indications for Renal Artery Stenting
Get PDFRenal artery stenosis (RAS) is a relatively common condition in the elderly, especially in the setting of concomitant vascular disease in other anatomical sites and is most often of atheromatous origin. Rarely is it encountered in young women as a result of fibromuscular dysplasia. RAS is considered responsible for refractory or accelerated hypertension, progressive loss of renal function and deterioration of patients??? cardiovascular status, with episodes of angina or pulmonary oedema disproportional to the extent of coronary artery disease and left ventricle functional capacity, dominating the clinical presentation. This article summarizes the pathophysio logical implications and diagnostic methods and attempts a review of the current literature on indications and efficacy of the available therapeutic options for RAS, focusing on interventional treatment. Renal artery stenosis (RAS) is most commonly due to atherosclerosis (???90%) or fibromuscular dysplasia (10%) and rarely to extrinsic compression, neurofibromatosis type I or Williams syndrome. Fibromuscular dysplasia predominates in young women (30-50 years old), is a nonatherosclerotic, noninflammatory vascular disease that causes stenosis in medium and small arteries, most commonly involving the distal 2/3 of the renal artery and carotid arteries. Atherosclerotic renal artery stenosis is usually encountered in males over 55 years old and often occurs at the ostium or the proximal 2 cm of the artery. [1,2] Refractory hypertension, progressive renal function deterioration and recurrent episodes of decompensated heart failure or flash pulmonary oedema are the most common clinical manifestations of the disease Both conservative and interventional treatment have been proposed and applied with comparable efficacy, as far as atherosclerotic disease is concerned and thus certain controversies have arisen regarding the treatment of choice.[3
Novel Technology for Ablation of Atrial Fibrillation Using Multi- Electrode Catheters and Duty-Cycled Radiofrequency Energy
Get PDFThese are fluoroscopic views of the heart demonstrating the use of novel technology for catheter ablation of atrial fibrillation (AF) in a patient who has had frequent episodes of paroxysmal AF and had failed antiarrhythmic drug therapy. In the upper panels, a steerable guiding catheter has been introduced via a transseptal approach into the left atrium and inserted into the right upper (left upper panel) and left upper (right upper panel) pulmonary veins (PVs), which are visualized with hand injection of contrast material. Subsequently, through the same guiding catheter, another deflectable circular multi-electrode (decapolar) 9-F catheter is inserted over a guide-wire and stabilized at the antrum of each PV (lower panels). Via this catheter, simultaneous mapping and ablation is performed by delivering duty-cycled unipolar and bipolar radiofrequency (RF) energy at 4-10 Watts with use of a multichannel RF generator. Thus, electrical isolation of the PVs is effected by delivering RF energy simultaneously to multiple points in the perimetry of the PV antrum, rather than employing extensive point-by-point or stepwise ablation with use of conventional single electrode catheters. With this novel technology, the procedure appears potentially safer and more efficiently performed with a shorter procedural time in a simplified approach compared with the conventional single-electrode catheter technique
Rheumatic Tricuspid Regurgitation after Left Valve Surgery
Get PDFA 77 old male presented with one year history of progressive dyspnea, upper abdominal discomfort and massive edema. He had an aortic and mitral valve replacement 10 years earlier for rheumatic involvement while tricuspid regurgitation on that time was reported as moderate and was left inoperable. Physical examination demonstrated prominent jugular V waves, grade III holosystolic murmur along the left lower sternal border, pulsatile hepatomegaly, ascites and massive lower extremity edema.Transthoracic echocardiogram revealed well functioning prosthetic left heart valves, a rheumatic tricuspid valve, severe tricuspid regurgitation (TR), plethoric inferior vena cava and right ventricular systolic pressure less than 40 mmHg suggesting the rheumatic than functional origin of TR. The right ventricle was dilated with impaired systolic function
Non-invasive Coronary Angiography: The Role, Limitations and Future of 64-slice Spiral CT Coronary Angiography
Get PDFConventional selective X-ray coronary angiography (SCA) remains the undisputed standard of reference for the assessment of the lumen of coronary arteries. However, this is an invasive procedure with a small but not negligible health risk that needs even short hospitalization and causes patient discomfort. Among the more than 2.5 million examinations of SCA performed annually in U.S.A. and Europe, approximately 25% do not reveal essential findings and more than 40% are not followed by any kind of interventional or surgical procedure. [1] On the other hand, SCA does not provide any information concerning the coronary wall, while almost 80% of deadly myocardial infarctions are attributed to vulnerable plaques which did not cause hemodynamically severe stenoses. [2] Thus, an effort for the development of non-invasive techniques for visualization of the coronary arteries is justified. Ideally, such a technique should be capable of reliably excluding or detecting significant stenoses of the coronary lumen and, at the same time, of assessing the coronary wall and plaque structure. By means of computed tomography (CT), this goal is being accomplished with two techniques; electron beam CT (EBCT) and multislice spiral CT (MSCT).EBCT was the first CT modality capable to provide diagnostic images of the proximal and mid segments of the coronary arteries, around 199 5, but it was abandoned soon after the advent of MSCT technology. [3,4
The Spectrum of Acquired Atrioventricular Block in Clinical Practice
Get PDFABSTRACT: Type I and type II second-degree AV block characterize block of a single sinus P wave:Type I block describes visible, varying and generally decremental AV conduction and type II block describes apparent all-or-none conduction without visible changes in AV conduction time before and after the blocked impulse. Absence of sinus slowing is an important criterion of type II block because a vagal surge (generally benign) can superficially resemble type II block. The diagnosis of type II block cannot be established if the first postblock P wave is followed by a shortened PR interval or is not discernible. All correctly defined type II blocks are infranodal. A pattern resembling narrow QRS Type II block together with an obvious type I structure in the same recording effectively rules out type II block because the co-existence of both types of narrow-QRS block is rare. Narrow QRS type I block is almost always AV nodal whereas type I block with bundle branch block outside acute myocardial infarction is infranodal in 60-70 % of cases. 2:1 AV block cannot be classified in terms of type I or II blocks and can be nodal or infranodal. Pacing is indicated in symptomatic marked first-degree AV block (>0.30 sec.), but patients with systolic heart failure might benefit more with biventricular pacing. Permanent pacing is almost never needed after inferior myocardial infarction and narrow QRS AV block. It should be considered only if second- or third-degree AV block persist for 14-16 days. Patients with bundle branch block and transient secondand third-degree AV block during anterior myocardial infarction have a high risk of sudden death after hospital discharge usually from ventricular tachyarrhythmias rather than AV block. They should receive an implantable cardioverter- defibrillator rather than a stand-alone pacemaker in the setting of severely depressed systolic left ventricular function. There are many causes of atrioventricular (AV) block but progressive idiopathic fibrosis of the conduction system related to an aging process of the cardiac skeleton is the most common cause of chronic acquired AV block. Barring congenital AV block, Lyme disease is the commonest cause of reversible third-degree AV block in young individuals and it is usually AV nodal. Before implantation of a permanent pacemaker, reversible causes of AV block such as Lyme disease, hypervagotonia, athletic heart, sleep apnea, ischemia, and drug, metabolic, or electrolytic imbalance must be excluded. Table 1 outlines the format used in the 2002 American College of Cardiology/American Heart Association/ North American Society of Pacing and Electrophysiology (ACC/AHA/NASPE) guidelines for pacemaker implantation [1]. The indications for permanent pacing in second- or third- degree AV block unlikely to regress are often straightforward in symptomatic patients but they are more difficult in asymptomatic patients. Some of the ACC/AHA/NASPE guidelines appear somewhat dogmatic. The final responsibility rests with the physician in terms of decisions, and the guidelines only represent a basic framework to start from
New Oral Antithrombotic Drugs
Get PDFNew oral antithrombotic drugs are currently used for several indications, but mostly for the long-term treatment or prevention of thromboembolic disease in situations such as high-risk orthopedic surgery, deep vein thrombosis and myocardial infarction. They are also used in atrial fibrillation for the prevention of stroke. This family of drugs includes anti-platelet agents, eg. ticlopidine and clopidogrel, antithrombin agents, eg. ximelagatran and several others with various mechanisms of action. Oral intake has to fulfill certain conditions regarding absorption, efficacy and safety
P Wave Dispersion: a valuable non-invasive marker of vulnerability to atrial arrhythmias
Get PDFThe prolongation of intraatrial and interatrial conduction time and the non-homogeneous propagation of sinus impulses are well known electrophysiologic characteristics in patients with atrial arrhythmias and especially paroxysmal atrial fibrillation (AF). Previous studies have demonstrated that individuals with clinical history of paroxysmal AF show a significantly increased P wave duration in 12-lead surface electrocardiograms (ECG) and signal-averaged ECG recordings. The inhomogeneous and discontinuous atrial conduction in patients with atrial arrhythmias has been studied, during the last years, with a new ECG index, P wave dispersion. P wave dispersion is defined as the difference between the longest and the shortest P wave duration recorded from multiple different surface ECG leads. Extensive clinical evaluation of P wave dispersion has been performed in the assessment of the risk for AF in patients without apparent heart disease, in hypertensive patients, in patients with coronary artery disease, in patients undergoing coronary artery bypass surgery, in patients with congenital heart diseases, as well as in other groups of patients suffering from various cardiac or non-cardiac diseases. P wave dispersion has proven to be a sensitive and specific ECG predictor of AF in the various clinical settings. However, the methodology used for the calculation of P wave dispersion has not been standardized so far and more efforts to improve the reliability and reproducibility of P wave dispersion measurements are needed. In conclusion, P wave dispersion constitutes a significant contribution to the field of non-invasive electrocardiology and seems to be quite promising in the field of AF prediction