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Biomedical subjects

D D Tresch

Publications and source records attributed to D D Tresch.

At least 19 recordsLinked to original sources
PubMed2001

Evaluation and management of cardiac arrhythmias in the elderly.

Cardiac arrhythmias are common in elderly patients. Complete evaluation with detection of underlying structural heart disease and comorbidities is necessary. Prognosis is dependent on the presence of underlying heart disease, particularly the degree of ventricular dysfunction and the presence of comorbidities. Long-term prognosis is excellent in patients without underlying heart disease or severe comorbidities. Management and specific drug therapy in elderly patients with arrhythmias need to be individualized in reference to the underlying cardiac disorder, drug side effects, and the patient's comorbidities.

Age Factors↗
PubMed2000

Clinical manifestations, diagnostic assessment, and etiology of heart failure in elderly patients.

Heart failure in elderly patients may be difficult to diagnose because of a lack of typical symptoms and physical findings that are common in younger patients with this disorder. When present, the symptoms and signs are often nonspecific and mistakenly may be thought to be caused by other disorders that are commonly present in elderly patients. In older elderly patients, the symptoms and signs may be obscured by the presence of aging changes or other diseases. As a result of these problems, physicians must be highly suspicious of heart failure in all elderly patients who have underlying heart disease or who present with nonspecific symptoms that may represent heart failure. After the diagnosis of heart failure is established, the cause must be determined and systolic and diastolic ventricular dysfunction must be differentiated.

Age Factors↗
PubMed2000

Use of oral anticoagulants in older patients.

Recently published American and British guidelines have comprehensively reviewed the indications for long term anticoagulation. The best evidence currently available supports the use of long term oral anticoagulants in patients with nonvalvular atrial fibrillation (NVAF), venous thromboembolic disease, ischaemic heart disease, mural thrombi, and mechanical heart valves. Selected patients with valvular heart disease, cerebral vascular disease, and peripheral arterial disease may also benefit from the use of these drugs. When no specific contraindications are present, elderly patients with either paroxysmal or persistent NVAF should be considered candidates for treatment with anticoagulants. Pooled analyses of the results from 9 randomised trials demonstrate that warfarin significantly reduces the risk of ischaemic stroke in patients with NVAF, particularly those in a 'high risk' category defined by the presence of additional clinical or echocardiographic risk factors. Long term anticoagulation does not appear to be justified in patients with NVAF considered to be at 'low risk' for stroke. Because the prevalence of NVAF and most other cardiovascular conditions increases with advancing age, many elderly patients will be candidates for thromboprophylaxis. The potential benefit of long term anticoagulation must be carefully weighed against the risk of serious haemorrhage in such patients. Bleeding complications with anticoagulant drugs appear to occur more frequently in older patients than in younger individuals. Advanced age (>75 years), intensity of anticoagulation [International Normalised Ratio (INR) >4.0], history of cerebral vascular disease (recent or remote), and concomitant use of drugs that interfere with haemostasis [aspirin (acetylsalicylic acid) or nonsteroidal anti-inflammatory drugs] are among the most important variables in determining an individual's risk for major bleeding with anticoagulants. Older patients often display increased sensitivity to the effects of warfarin, both in the early induction phase and during the long term maintenance phase of therapy. Conditions such as congestive heart failure, malignancy, malnutrition, diarrhoea and unsuspected vitamin K deficiency, enhance the prothrombin time response. The decision to interrupt anticoagulant therapy before elective surgery in elderly patients should evaluate the thrombotic risk of such a manoeuvre versus the risk of bleeding if anticoagulants are continued. In non-surgical patients, excessively elevated INRs without associated haemorrhage can usually be managed by simply witholding one or several doses of warfarin. If more rapid reversal is needed, small doses of phytomenadione (vitamin K1) can be administered safely without overcorrection or the development of vitamin K-induced warfarin resistance.

Administration, Oral↗
PubMed1998

Ventricular arrhythmias in the elderly.

Sudden cardiac death (SCD) remains a significant medical problem in the United States. The incidence of SCD increases with advancing age because cardiovascular disease is more prevalent in the elderly. Management of ventricular arrhythmias in the elderly patient is especially challenging because of increased risk of interventional and pharmacologic therapies, altered pharmacokinetics of drugs, and sometimes unclear long-term benefits.

Aged↗
PubMed1998

Cardiopulmonary resuscitation in the elderly. Beneficial or an exercise in futility?

Sudden cardiac death is one of the leading causes of death and a major public health problem that particularly affects the elderly. Sudden cardiac death may be a terminal event after a prolonged debilitating and painful illness, or it may occur following many years of symptoms related to a cardiac disorder; however, in many elderly persons, the cardiac arrest may be the first manifestation of cardiac disease in a supposedly healthy and physically active person. Whether cardiopulmonary resuscitation should be performed in elderly patients who sustain cardiac arrest is a significant issue confronting the medical profession and the general public. Several questions must be answered when evaluating the decision of whether or not to perform cardiopulmonary resuscitation on an elderly patient.

Aged↗
PubMed1998

Management of the older patient with acute myocardial infarction: difference in clinical presentations between older and younger patients.

The majority of persons sustaining acute myocardial infarction are older, and in these older persons morbidity and mortality are high. Clinical presentations and characteristics are significantly different between older and younger infarction patients. Older infarction patients are more likely to be female and to have a history of heart failure, but they are less likely to have a family history of myocardial infarction, elevated cholesterol, or to smoke. Older patients will frequently have unrecognized or silent myocardial infarctions or, when present, symptoms will be atypical. Instead of chest pain, older patients may have shortness of breath or neurological symptoms, such as confusion. Also, older infarction patients will delay longer in seeking medical assistance after onset of symptoms, and often will not demonstrate ST elevation or Q waves on their electrocardiograms. Not infrequently, older infarction patients will demonstrate major complications such as heart failure or right ventricular infarction on hospital admission, and their presenting complaints will reflect these complications. Because of these atypical presentations and the wide variability of symptoms, physicians must be highly suspicious of the presence of an acute myocardial infarction in older patients who have an unexplained acute change in their physical condition.

Age Factors↗
PubMed1997

The clinical diagnosis of heart failure in older patients.

OBJECTIVE: To review the differences in presentation and clinical manifestation of heart failure in older and younger patients and to determine if these differences influence the ability to diagnose the disorder clinically. Based on this information, an approach to diagnosing heart failure in older patients is provided. DATA SOURCE: Scientific reports regarding heart failure in both the general population and the geriatric population were identified from repeated searches of MEDLINE data base and citations from appropriate articles. DATA EXTRACTION AND SYNTHESIS: Relevant data were obtained from articles, with special importance placed on studies designed to examine older patients exclusively or as a subgroup in a larger study. Review of data pertaining to clinical characteristics and presentation of heart failure was performed, with emphasis on comparing the characteristics between age groups. Specific cardiac diseases that cause ventricular impairment in older patients were assessed, and the importance of systolic versus diastolic dysfunction in this age group was analyzed. CONCLUSION: Clinical diagnosis of heart failure in older patients may be difficult because of the absence of typical symptoms and physical findings. When present, the symptoms and signs may be mistakenly diagnosed as caused by concomitant disorders or aging changes. In other older patients, the symptoms and signs will be obscured by the presence of aging changes or the presence of other diseases. As a result of these difficulties, the initial diagnosis of heart failure in older patients is made later in the course of the cardiac disease process; older patients will be more unstable, and secondary preventive therapies may be of less benefit than in younger patients with the disorder. Though clinically difficult, the differentiation between systolic and diastolic ventricular dysfunction is mandatory in all older patients with heart failure.

Age Factors↗
PubMed1996

Comparison of elderly and younger patients with out-of-hospital chest pain. Clinical characteristics, acute myocardial infarction, therapy, and outcomes.

BACKGROUND: Acute myocardial infarction is associated with significantly higher mortality in elderly patients compared with younger patients. OBJECTIVES: To determine clinical differences in elderly and younger patients with acute myocardial infarction. To assess differences in therapies and outcomes between the age groups. METHODS: Over a 3.5-year period, 2482 consecutive adult emergency medical services patients with chest pain received prehospital electrocardiograms and were entered in the Milwaukee Prehospital Chest Pain Database in Milwaukee, Wis. Clinical characteristics that included cardiac history, description of chest pain, time of onset to presentation, and prevalence of acute myocardial infarction were obtained for all patients. Patients with acute infarction were further analyzed in reference to type of infarction (Q wave vs non-Q wave), therapeutic interventions, and mortality. Patients were stratified in 3 age groups: younger than 70 years (younger), 70 years or older (elderly), and 80 years or older (very elderly); differences were compared among the age groups. RESULTS: Even though more than 50% had a history of documented coronary artery disease, elderly patients with ischemic chest pain delayed more than 6 hours in seeking medical assistance after onset of pain. In elderly patients whose chest pain represented an acute myocardial infarction, hospital mortality was double that of younger patients. Thrombolytic therapy reduced hospital mortality by approximately 50% in both younger and elderly patients, although thrombolytic therapies were used in only 17% of the elderly patients compared with 50% of the younger patients (P < .001). Revascularization procedures were also beneficial in elderly patients as well as in younger patients, although this procedure, as with thrombolytic therapy, was less frequently used in elderly patients (48% vs 32%, P < .001). CONCLUSIONS: Effective methods for reducing time delays from onset of chest pain to accessing health care for elderly persons deserve investigation. Physicians should be aware of the benefits of thrombolytic and revascularization therapies in elderly patients with acute myocardial infarction.

Adult↗
PubMed1996

Circadian variation in sudden cardiac death: effects of age, sex, and initial cardiac rhythm.

STUDY OBJECTIVE: Previous studies based on data obtained from vital statistics records have demonstrated circadian variation in the occurrence of sudden cardiac death. The purpose of this study was to examine the effects of age, sex, and initial cardiac rhythm on circadian variability in sudden cardiac death. METHODS: This study employed a retrospective analysis of the records of adult patients with witnessed cardiac arrest who underwent resuscitation in an urban paramedic system during a 5-year period. RESULTS: The records of 2,250 consecutive patients with witnessed cardiac arrest were reviewed. Spectral analysis was used to decompose the data into frequency components. A circadian variation in the occurrence of sudden cardiac death was demonstrated, with a low occurrence rate between midnight and 6 AM and a 2.4-fold increase between the rate at 6 AM and the rate at noon. The same circadian pattern was noted among both men and women, among both patients aged 18 to 70 and those older than 70 years, and among patients with various initial cardiac arrest rhythms (ventricular tachycardia or fibrillation, asystole, and electromechanical dissociation). However, the outcome of resuscitation in these patients (ie, the rate of successful resuscitation and the rate of survival) did not demonstrate circadian variation. CONCLUSION: Witnessed out-of-hospital sudden cardiac death demonstrated circadian variation, and this variability was observed regardless of the patient's age, sex, or initial cardiac arrest rhythm. The outcome of resuscitation did not show circadian variability. These results suggest a common pathophysiologic mechanism leading to sudden cardiac death.

Adolescent↗
PubMed1996

Smoking and coronary artery disease.

This article discusses the specific effects of smoking on the heart and coronary arteries and demonstrates how these effects increase the risk for cardiovascular morbidity and mortality. The conflicting results of various studies concerning the association of smoking and coronary heart disease in older persons are reviewed, and possible explanations for the discrepancy are given. Recent trends in smoking habits in the United States and the effects of these changing trends on cardiovascular mortality are presented. Finally, data are presented that demonstrate the effects of physician-directed cessation programs and the health benefits of smoking cessation in elderly and younger persons.

Aged↗
PubMed1996

Clinical manifestations and diagnosis of coronary artery disease.

Coronary atherosclerosis is very common in the elderly population with autopsy studies demonstrating the prevalence to be at least 70% in persons over the age of 70. These autopsy findings may be coincidental, with the disease clinically silent throughout the person's life, although 20% to 30% of persons over age 65 years will demonstrate clinical manifestations of coronary heart disease (CHD). In most elderly persons, the disease will have manifested itself much earlier in their lives, however, in others the disease will be entirely silent until the person reaches his or her 70s or 80s. Unfortunately, even though CHD is prevalent in elderly persons, the disease is often not diagnosed or misdiagnosed in this age group. Failure to correctly diagnose the disease in the elderly may be due to the difference in the clinical manifestation in this age group compared with younger patients. Such differences may reflect a difference in the disease process between older and younger patients or it may be related to the superimposition of normal aging changes, plus the presence of concomitant diseases, which may mask the usual clinical manifestations.

Aged↗
PubMed1995

Characteristics of residents with do-not-resuscitate orders in nursing homes.

We determined patient characteristics associated with do-not-resuscitate (DNR) status in nursing homes using cross-sectional analysis of secondary data derived from Minimum Data Set documents in 14 nursing homes from one state in the upper Midwest. The primary outcome variable was DNR status. Bivariate analysis was first carried out on all variables. Variables associated with DNR status at this stage were then included in a stepwise logistic regression to determine variables independently associated with DNR status. Overall, 71% of patients had DNR orders. Variables found to be independently associated with a higher probability of DNR status were increasing age, female gender, worse cognitive function, durable power of attorney, being self-paying, or having commercial insurance. Lack of daily contact with relatives and friends and lack of involvement with others were associated with lower probability of DNR status. A higher prevalence of DNR status in nursing homes was seen than in prior literature. The patient characteristics shown to be associated with DNR status may give important insight into the reasons that such decisions are made.

Age Factors↗
PubMed1995

Heart failure with normal systolic function: a common disorder in older people.

OBJECTIVE: To review the incidence, pathophysiology, significance, diagnosis, and treatment of heart failure with normal systolic function in older patients. DATA SOURCE: Scientific reports of diastolic ventricular dysfunction in both the general population and the geriatric population were identified from repeated searches of the MEDLINE database and citations from appropriate articles. STUDY SELECTION: Studies were included only if they demonstrated proper methodology, were from a reputable source, and were published in a peer-reviewed journal. DATA EXTRACTION AND SYNTHESIS: Relevant data were obtained from the articles, with special importance placed on studies designed to examine older patients exclusively or as part of a subgroup in a larger study. Emphasis was placed on data pertaining to the pathophysiology, prognosis, and diagnosis of patients with diastolic dysfunction compared with normals and patients with systolic dysfunction as an etiology of heart failure. Therapeutic interventions were selected for the presence of prospective data with concrete end points such as mortality, functional class, exercise capacity, and regression of left ventricular hypertrophy. CONCLUSION: Diastolic ventricular dysfunction is a significant problem in older people, with at least 40% of older heart failure patients having diastolic dysfunction as the etiology of their heart failure. The pathophysiology of diastolic dysfunction is varied but usually involves impaired left ventricular relaxation and/or increased ventricular stiffness, each partially related to normal aging changes, as well as underlying cardiovascular diseases. The significance of heart failure caused by diastolic dysfunction is great, with increased morbidity and mortality compared with other cardiac diseases that have the same preserved systolic function. Diagnosis of diastolic dysfunction can be clinically difficult and often requires further testing to determine if diastolic dysfunction is present. At this time, no therapy specifically treats diastolic dysfunction, but several medications, such as diuretics, calcium channel blockers, beta blockers, and angiotension-converting enzyme inhibitors, offer symptomatic relief and may prevent progression of the disorder.

Aging↗
PubMed1995

Diagnostic and prognostic value of ambulatory electrographic monitoring in older patients.

OBJECTIVE: To review the use of ambulatory electrocardiographic monitoring in detecting transient cardiac arrhythmias and myocardial ischemia in older patients and to determine the significance of these findings in predicting future cardiac events. DATA SOURCES: Reports on ambulatory electrocardiographic monitoring's capabilities in the detection and quantification of arrhythmias and myocardial ischemia were identified by multiple searches on the MEDLINE database and citations from relevant articles. STUDY SELECTION: Studies that demonstrated good research methodology were reviewed. Review was limited to studies that used reel-to-reel or cassette recorders (not reel-time monitors). DATA EXTRACTION AND SYNTHESIS: Pertinent data were extracted from the studies, with specific emphasis on studies involving older patients. Prognostic findings were critically analyzed and compared between younger patients and older patients. Differences in prognoses younger patients with and without underlying heart disease were assessed. CONCLUSION: Ambulatory electrocardiographic monitoring is a noninvasive procedure that is beneficial in stratifying older patients with heart disease into high and low risk groups for future cardiac events. The presence of complex ventricular arrhythmias or silent myocardial ischemia as documented on 24-hour monitoring, especially in combination with left ventricular dysfunction or left ventricular hypertrophy, is highly predictive of future cardiac events, including sudden cardiac death and total cardiac mortality. The use of preoperative, intraoperative, and postoperative electrocardiographic monitoring may also be beneficial in stratifying older surgical patients into high and low risks for postoperative cardiac events.

Aged↗
PubMed1994

The role of implantable cardioverter defibrillators in non VT/VF sudden deaths.

Implantable cardioverter defibrillator (ICD) therapy has been an impressive success in preventing sudden cardiac death (SCD). Electrocardiographic documentation of SCD in ICD patients has been rare, but usually arrhythmias other than ventricular tachycardia/ventricular fibrillation (VT/VF; asystole and electromechanical dissociation [EMD]) have been implicated. This raises the question whether backup bradycardia pacing can prevent deaths due to asystole and EMD in such patients. We studied the outcome of 88 patients with permanent bradycardia pacemakers and compared them to 500 consecutive nonpacemaker patient controls, sustaining out-of-hospital cardiac arrest and undergoing resuscitation by paramedics. Mean age of the pacemaker patients was 73.5 +/- 10.3 years and 64% males, compared to mean age of 68.2 +/- 6.7 years and 67% males in the control group. Overall success of resuscitation and survival rates were similar. When the documented rhythm was VT/VF or asystole there were no differences in resuscitation or survival rates for the pacemaker or nonpacemaker patients. However, resuscitation rate was significantly higher in pacemaker patients than nonpacemaker patients with EMD: 47% versus 20% (P < 0.03). For EMD, survival rate for the pacemaker patients was 13% compared to 5% in the nonpacemaker patients, but this difference was not statistically significant. Backup bradycardia pacing in future generation devices may improve the outcome of non VT/VF sudden cardiac death in at least some of the ICD recipients.

Aged↗
PubMed1993

Outcomes of cardiopulmonary resuscitation in nursing homes: can we predict who will benefit?

PURPOSE: To determine the benefits of cardiopulmonary resuscitation (CPR) in nursing home patients and assess possible prearrest and arrest predictors of survival. PATIENTS AND METHODS: During a 4-year period (1986 to 1989), consecutive nursing home patients from Milwaukee, Wisconsin, who sustained cardiac arrest and received CPR by paramedics were studied. The patients' prearrest clinical characteristics were determined including age, length of stay in nursing home, medical diagnoses, medications, circumstances surrounding the arrest, laboratory studies, and baseline functional status. Cardiac arrest data were obtained from a paramedic computer data base and included whether the arrest was witnessed, initial cardiac rhythm, and success of CPR. Survival was defined as the discharge of the patient alive from the hospital, and the patient's pre- and post-arrest functional status was compared. Possible predictors of survival were analyzed from the patient's prearrest characteristics and arrest characteristics. RESULTS: Of the total 196 patients who received CPR, 37 (19%) were successfully resuscitated and hospitalized, and 10 (5%) survived to be discharged. However, 27% of patients survived whose arrests were witnessed and who demonstrated ventricular fibrillation at the time of the arrest. In comparison, only 2.3% of all other nursing home patients who received CPR survived (p < 0.0002). Age, mental or functional status, hematocrit, renal dysfunction, pulmonary disease, cancer, and cardiovascular disease were not significant predictors of survival. At the time of hospital discharge, the functional status of the majority (80%) of the survivors was comparable to their prearrest status and 40% of the survivors lived for greater than 12 months. CONCLUSION: We conclude that only a small percentage of nursing home patients who sustain cardiac arrest will benefit from CPR. However, greater than 25% of nursing home patients whose arrest is witnessed and who demonstrate ventricular fibrillation will survive. This is comparable to the survival rate of elderly community-dwelling persons who sustain cardiac arrest. Our data suggest that CPR should be initiated only in nursing home patients whose cardiac arrest is witnessed and should only be continued in patients whose initial documented cardiac rhythm is ventricular fibrillation or ventricular tachycardia.

Adult↗
PubMed1991

Patients in a persistent vegetative state attitudes and reactions of family members.

Patients in a persistent vegetative state (PVS) constituted approximately 3% of the population in four Milwaukee nursing homes. In order to understand family members' attitudes and reactions toward such patients, 33 (92%) of 36 family members of patients in PVS contacted were studied. The age of the patients ranged from 19 to 95 with a mean age of 73.4 +/- 17.2 years, and family members' ages ranged from 41 to 89 with a mean age of 61.8 +/- 3.3 years. The etiology of the PVS varied from dementia to cerebral trauma. The mean duration of the PVS was 54 +/- 8.4 months (range 12 to 204). Family members reported that they visited patients 260 times during the first year following the onset of the PVS and were still visiting at a rate of 209 visits yearly at the time of the interview. There was no significant correlation between the frequency of the family members visits and the duration of the PVS, the patient's or family member's age, or the family member's relationship to the patient. Ninety percent of patients were considered by family members to have some awareness of pain, light or darkness, environment, taste, verbal conversation, or the family member's presence. Most family members thought they understood the patient's medical condition, and the majority did not expect the patient to improve. Nevertheless, the majority of family members wanted the patient to undergo therapeutic interventions, including transfer to the acute hospital and surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗