Biomedical subjects
Publications and source records attributed to L Lemberg.
Classification of antiarrhythmic drugs based on their electrophysiologic and hemodynamic properties coupled with an understanding of the transmembrane action potential of the cardiac cell (see the first of this series of six vignettes) help in the appropriate choice of therapy in a given clinical setting.
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Symptomatic bradycardia-tachycardia is often a feature of sick sinus syndrome. However, when alternating brady-tachycardia results from excessive use of digitalis preparations or electrolyte imbalance, it is iatrogenic and therefore not considered to be SSS per se. Sick sinus syndrome is applied to the following arrhythmias providing they are not iatrogenically induced: (1) sinus bradycardia usually unresponsive to atropine therapy or exercise, (2) sino-atrial block or arrest with long pauses, and (3) alternating bradycardia or tachycardia.
An example of junctional premature beats with concealed conduction has been presented. The arrhythmia mimics Mobitz Type II second-degree A-V block. Awareness of this arrhythmia when added to the fact that Mobitz Type II block is rarely seen with IWMI will prevent an improper or hasty diagnosis. Cardiac arrhythmias should be interpreted and managed in context of the clinical setting.
This vignette demonstrates the importance of analyzing arrhythmias in the context of their particular clinical setting. Analysis and treatment of an arrhythmia without clinical information leads to errors in judgment. Arrhythmias may be interpreted as a didactic exercise that is used in the process of teaching and learning. However, when the question is asked, "How do you treat this arrhythmia?", then all clinical information ambient to the arrhythmia in question has to be available for analysis and judgment.
The adequate interpretation of cardiac arrhythmias should be done in context with the clinical facts. In case of arrhythmias induced by pacemakers, it is essential to have detailed information about the characteristics of the electronic instrument. This paper shows, that only with precise information about the electrophysiological facts of a certain instrument, it is possible to diagnose the origin of an arrhythmia, its significance related to normal function or disfunction of the apparatus and the proper measures can be taken for correcting the disorder. Examples of clinical cases have been presented, and undoubtedly a growing improvement in the elaboration of the electronic instruments, will enrich, the already ample field of cardiac arrhythmias. All of it will lead to an undoubtful benefit for patients, medical personnel who are involved in the electric treatment of the disturbances in rhythm and conduction.
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An acute MI complicating advanced COPD is an unusual clinical occurrence. Nevertheless, when these diseases coexist the appropriate use of blood gas analysis and the appreciation of their inherent problems will improve the prognosis. This vignette attempts to point out these problems and their management.
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The rehabilitation of the complicated-MI patient in the CCU should consist of early use of the bedside chair and progressive activity with the level and rate of advancement determined by frequent assessment of the clinical state. Patient education is an important part of the rehabilitation program, especially in the patient with complicated MI.
Treadmill cardiac stress tests have a number of well known, identifiable criteria for positivity. One that is less known and thus often not appreciated, is the appearance of an inverted U wave in the left chest leads at the peak of exercise. This, even as an isolated finding, indicates a positive test. Of clinical significance is that this electrocardiographic response to a stress test is associated with an isolated lesion of the left anterior descending coronary artery.
Cardiac exercise stress testing has both diagnostic and prognostic implications. ECG changes, hemodynamic responses, and symptoms during exercise are clues to the functional capacity, severity of coronary artery disease, and probability of future coronary events. The time and workload required for a positive response to exercise and the length of time the ECG changes persist during recovery are indicators of the degree of coronary disease and are useful in predicting future coronary events.
Acute onset of atrial fibrillation during the early period of an MI does not require antiarrhythmic therapy if the ventricular response is not excessive and the patient is hemodynamically stable. The use of diuretics and/or unloading agents, determined by the degree of CHF, is the preferred management. Use of digitalis glycosides is potentially hazardous because of the possibility of precipitating A-V block in patients with acute A-V nodal injury.
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