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PubMed2006

[Guidelines for the management of acute stroke--2005].

Stroke is a major cause for morbidity and mortality in Israel, the third most common cause of death and the main cause for neurological disability among adults. Several significant breakthroughs occurred over recent years in the management of stroke, and acute stroke has increasingly been recognized as a medical emergency--a "brain attack" comparable to a "heart attack". Several new scientific publications, guidelines and consensus statements from Europe and North America necessitate a paradigm shift in the management of acute stroke. The guidelines focus on a number of issues: acute stroke as a medical emergency, dedicated stroke units, early reperfusion therapy for acute ischemic stroke, emergency management and general stroke treatment, use of diagnostic tests in the acute phase, and the prevention and treatment of complications.

Acute Disease↗
PubMed1983

Adolescent chest pain: a prospective study.

One hundred adolescents with chest pain were prospectively analyzed to determine the etiology, functional consequences, and illness attributions of patients seen in a general pediatric clinic. The typical patient had frequent pain (63% had two or more episodes weekly) of moderate duration (51% of the pain lasted longer than six minutes) that had been occurring for many months (36% had pain occurring longer than 6 months). Stressful events, such as a death in the family, major illness, an accident, family separations, and school changes occurred in 31% of patients. The most frequently diagnosed condition was musculoskeletal problems (31%) including costochondritis (14%), chest wall syndrome (13%), skeletal trauma (2%), and ribcage anomalies (2%). Hyperventilation accounted for 20% of diagnoses and 5% had breast-related problems. Thirty-nine percent of patients had pain not readily classifiable. Serious underlying illness was a rare cause of chest pain, although several patients had associated organic disease not responsible for their chest pain. More than two thirds of patients restricted physical activities; more than 40% were absent from school. When patients were questioned about their understanding of their illness, 44% were afraid that they were experiencing a heart attack, 12% worried about heart disease, and 12% feared cancer. Chest pain is a prevalent problem that is usually benign but is commonly misunderstood and causes considerable dysfunction and anxiety in adolescents.

Adolescent↗
PubMed1982

[Mobile coronary unit of Florence: early care of arrhythmias not due to acute coronary insufficiency].

The aim of Mobile Coronary Care Units (M.C.C.U.) is to reduce the delay in delivering intensive care to patients with a heart attack. In the city of Florence a M.C.C.U. has been available since November 1979. During the first year the staff of the M.C.C.U. has treated 158 cases of serious cardiac arrhythmias which occurred among 486 interventions. In 94 patients cardiac arrhythmias followed an acute coronary attack. In 64 patients coronary heart disease could not be demonstrated. This study concerns the latter group of patients. The mean age was 65.2 years and 39 patients (61%) were women. The mean time from the onset of the symptoms to the arrival of the M.C.C.U. team was 3h and 2 min, whereas the mean time from the call to the arrival was 14 min. Sixty patients had atrial arrhythmias (29 atrial fibrillation, 2 atrial flutter, 22 atrial tachycardia, 7 premature atrial contractions) and 4 patients had ventricular arrhythmias (1 ventricular tachycardia, 1 ventricular flutter, 2 premature ventricular contractions). In thirty-nine patients (61%) the cardiac arrhythmia was abolished by the staff of the M.C.C.U.. Of the remaining 28 patients, 10 were brought to the hospital and 18 were left at home. None of these needed later admission to the hospital. So the treatment at home of cardiac arrhythmias has been successful in the majority of patients. Bunaftine was the antiarrhythmic drug more frequently used (23 cases, 34%) with a high percentage of success (87%). In planning medical emergency services to the community, one can envisage the use of the M.C.C.U. facilities to treat at home those arrhythmias that are not associated with an acute coronary attack.

Adult↗
PubMed2005

Update on the drug treatment of hypertension in patients with cardiovascular disease.

The management of the high-risk patient with hypertension has become more challenging in recent years. Drug therapy should be initiated earlier and at lower blood pressure levels in patients with coexisting cardiovascular or kidney diseases. The blood pressure goals of drug therapy are substantially lower when patients have concomitant heart or kidney disease or diabetes mellitus. Numerous clinical trials in tens of thousands of hypertensive patients with increased cardiovascular risk have demonstrated that the calcium antagonists are as effective and safe as diuretics, beta-adrenergic blockers, and renin-angiotensin blocking agents to prevent heart attack and stroke but not heart failure. Several recent studies also demonstrate that angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers are effective in preventing stroke, progressive renal insufficiency, and heart failure in higher risk patients with hypertension. To achieve the aggressive blood pressure goals in patients with cardiovascular disease, thoughtful combinations of additive or synergistic agents improve efficacy and tolerability and have become an integral part of the modern management of hypertensive patients with coexisting cardiovascular disease.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1998

Epidemiology of risk in hypertensives: experience in treated patients.

Knowledge of the epidemiology of cardiovascular disease (CVD) in hypertensive patients derives primarily from observation of populations composed largely of untreated subjects. Increasingly, however, individuals with elevated blood pressure are treated. An 18-year observational study of 8690 participants in a systematic hypertension control project reveals that cardiovascular events continue to be the principal morbid and mortal outcomes. Over time, the incidence of stroke and heart attack remained stable, whereas congestive heart failure (CHF), as a first event, increased tenfold after 10 years. Diabetes and evidence of vascular disease at entry predicted morbidity. Persisting cardiovascular morbidity in the face of satisfactory blood pressure control suggests the need for additional preventive intervention.

Age Factors↗
PubMed1997

Cardiological effects of catecholamine-secreting tumours.

Correlations between endocrine and cardiological findings were investigated in 106 patients with catecholamine-secreting tumours during the florid phase of their illness. Endocrine data showed an elevation of urinary catecholamine or vanillylmandelic acid excretion in all but one subject. Hypertension was found in 78%, symptoms of coronary heart disease in 26% and arrhythmias in 20% of the patients. Twelve per cent of the patients came to the hospital with heart attacks, 7% with acute left heart failure and 6% with myocardial infarction. At admission electrocardiograph (ECG) analysis showed a sinus rhythm in 98%, tachycardia > 100 min-1 in 14% and bradycardia < 60 min-1 in 10%. In 16% of the ECGs cQT was increased, in 17% the ST segment was lowered and in 37% abnormal T waves occurred. Indices of myocardial hypertrophy such as the Sokolow index, the modified Romhilt-Estes score and the Murphy score were raised in 29%, 19% and 38% respectively. In 23 of 51 (45%) patients echocardiography showed left ventricular hypertrophy, in 16% mitral valve insufficiency and in 24% disturbances of contractility. Comparison of cardiac and endocrine parameters confirm in vitro and animal studies indicating that, in particular, the alpha-mimetic noradrenaline (NA) has deleterious effects on the cardiovascular system. Urinary NA, but not adrenaline or dopamine, excretion was significantly higher in constantly hypertensive than in normotensive patients and associated with an elevation of the Sokolow index and the Romhilt-Estes score. Both indices and plasma NA were higher in patients with myocardial hypertrophy and we found a significant correlation between the Romhilt-Estes score and NA excretion.

Adult↗
PubMed2006

Prevalence of multiple cardiac risk factors in US adults with diabetes.

PURPOSE: The National Cholesterol Education Program, Adult Treatment Panel III (NCEP ATP III) included diabetes mellitus (DM) as a risk factor for major coronary events equivalent to existing coronary heart disease (CHD). This study estimates the national prevalence of additional CHD risk factors for US adults with and without DM and heart disease using Medical Expenditure Panel Survey (MEPS) data. METHODS: In this retrospective study using nationally representative 2000 and 2002 MEPS survey data, DM and CHD for adult respondents (n = 44 481) were identified by ICD-9 codes or self-reported DM, coronary heart disease, angina, heart attack or stroke, or other heart disease. Six additional risk factors assessed were hypertension, hypercholesterolemia, smoking, age (> or = 45 years [men], > or = 55 years [women]), obesity, and physical inactivity. The national prevalence of cardiac risk factors was assessed in four subgroups: CHD-/DM-; CHD-/DM+; CHD+/DM-, CHD+/DM+. RESULTS: The CHD-/DM+ group had significantly higher mean risk factor counts than did the CHD-/DM- group and the CHD+/DM- group (2.6 versus 1.4 and 2.4, respectively; both p < 0.01). The CHD+/DM+ group had the highest mean risk factor count at 3.4. Proportions of US adults in each subgroup with two or more risk factors were CHD-/DM-: 39.5%; CHD-/DM+: 81.9%; CHD+/DM-: 74.9%; CHD+/DM+: 95.1%. Limitations of this study include the use of self-reported data and the lack of data regarding family history of CHD, both of which are likely to result in conservative prevalence estimates. CONCLUSION: Results presented here indicate that diabetes, with or without co-morbid heart disease, is associated with a high prevalence of cardiac risk factors in US adults. The prevalence estimates reported here demonstrate the extensiveness of this public health issue. It is essential that medical providers treat modifiable risk factors in patients with diabetes aggressively with lifestyle modifications and pharmacotherapy consistent with NCEP ATP III recommendations.

Coronary Disease↗
PubMed2006

[Effect of oral cordarone in reversing persistent atrial fibrillation].

OBJECTIVE: To observe the efficacy and safety of oral cordarone dir reversing persistent atrial fibrillation (AF). METHODS; Eighty-two symptomatic chronic AF out-patients without history of acute diseases or severe hepatic/thyroid dysfunction were given oral cordarone at the loading dose of 200 mg thrice a day for 1-4 weeks followed by a twice-daily administration for another 1-4 weeks, with the maintenance dose of 200 or 100 mg once a day. The incidence of stroke and cardiac events and the mortality rate were compared between 43 patients with restored rhythm on cordarone and 39 patients on digoxin and/or betaloc for ventricular rhythm control. RESULTS: Among the 82 patients, sinus rhythm restoration was achieved in 43, with a successful rate of 52%. In 18 patients, the ejection fraction increased from (32+/-8)% to (46+/-10)%, left atrium diameter decreased from (4.6+/-1.1) cm to (4.1+/-0.8) cm. Except for slight T4 increase, QT prolongation and bradycardia in 3 cases, severe side effects were not observed in this study. Only one patient with restored sinus rhythm required rehospitalization after half a year for worsened heart failure, but in patients with controlled ventricular rhythm, 1 developed stroke, 1 experienced heart attack and 1 died of heart failure with bleeding. CONCLUSION: For patients with symptomatic reversible persistent AF, active treatment with cordarone can be convenient, effective and safe for sinus rhythm restoration.

Adult↗
PubMed1993

Trends in nonfatal coronary heart disease in the United States, 1980 through 1989.

BACKGROUND: Although coronary heart disease mortality has been decreasing, little is known about trends in morbidity from coronary heart disease. We evaluated trends in nonfatal coronary heart disease in the United States during 1980 through 1989. METHODS: We analyzed data from the National Health Interview Survey, an ongoing survey of representative samples of the civilian, noninstitutionalized population of the United States. Survey respondents were determined to have coronary heart disease if they reported ever having a myocardial infarction or heart attack, angina pectoris, or coronary heart disease. Incidence was defined as initial onset of a coronary heart disease condition during the year preceding the interview date. RESULTS: About 6 million people were estimated to be living with coronary heart disease. The age-standardized prevalence was relatively constant at about 25 per 1000. Among white men, however, prevalence increased significantly over the 10-year period. Among 75- to 84-year-old men, prevalence increased from 100 per 1000 in 1980 to 179 per 1000 in 1989. Among men and women 45 to 54 years old, prevalence decreased. Overall, the incidence rate of nonfatal coronary heart disease was relatively flat (at about 3 per 1000 per year after 1983). Among white women, the incidence rate increased from 1.4 to 2.8 per 1000, and by the end of the decade it nearly equaled the incidence rate among white men. CONCLUSIONS: Overall, the burden of nonfatal coronary heart disease remained fairly constant during the 1980s. The trends, however, were not uniform in all population groups. The apparent increasing incidence among women deserves continued monitoring. An encouraging trend is the decreasing prevalence in the younger age groups.

Aged↗
PubMed1997

[Evaluation of the effectiveness of an ambulatory after-care rehabilitation program].

Effects of an outpatient cardiological rehabilitation programme that is offered to patients following their inpatient treatment in a rehab clinic are measured and compared with the data collected from an untreated group. The study group consists of 155 cardiological patients (after heart attack, bypass operation and heart-valve prosthesis) in the treatment group as well as 136 in the non-treatment group. The outpatient programme takes place twice a week in a cardiological rehab clinic, with patients participating for a maximum period of twelve weeks. Data are collected at the beginning, the end and three months after the end of the programme from the treatment group resp. twice with a six months interval from the non-treatment group. The used outcome measures are a number of medical variables (e.g. stress ECG, BMI, blood pressure), variables concerning vocational reintegration, plus a questionnaire. This questionnaire consists of a Functional Limitation Scale, a Mood Check List, a "Health Locus of Control"-Scale as well as a number of items regarding health-related behaviour and heart complaint symptoms. The project duration was 36 months, starting in June 1993. The funding source is the "Landesversicherungsanstalt Westfalen", a regional division of the German Statutory Old Age Insurance. As data concerning vocational reintegration indicate, the programme can be a meaningful complement to a larger amount of reintegrated patients (66.9%) compared to the non-treatment group (50.2%). To estimate the long-term effects of the programme, a 24-month-follow-up was started in January 1996.

Adult↗
PubMed1982

A randomized trial of propranolol in patients with acute myocardial infarction. I. Mortality results.

The beta-Blocker Heart Attack Trial (BHAT) was a National Heart, Lung, and Blood Institute-sponsored, multicenter, randomized, double-blind, and placebo-controlled trial designed to test whether the regular administration of propranolol hydrochloride to men and women who had experienced at least one myocardial infarction would result in a significant reduction in total mortality during a two- to four-year period. During a 27-month interval, 3,837 persons between the ages of 30 and 69 years were randomized to either propranolol (1,916 persons) or placebo (1,912 persons), five to 21 days after the infarction. Depending on serum drug levels, the prescribed maintenance dose of propranolol hydrochloride was either 180 or 240 mg/day. The trial was stopped nine months ahead of schedule. Total mortality during the average 24-month follow-up period was 7.2% in the propranolol group and 9.8% in the placebo group. Arteriosclerotic heart disease (ASHD) mortality was 6.2% in the propranolol group and 8.5% in the placebo group. Sudden cardiac death, a subset of ASHD mortality, was 3.3% among the propranolol patients and 4.6% among the placebo patients. Serious side effects were uncommon. Hypotension, gastrointestinal problems, tiredness, bronchospasm, and cold hands and feet occurred more frequently in the propranolol group. Based on the BHAT results, the use of propranolol in patients with no contraindications to beta-blockade who have had a recent myocardial infarction is recommended for at least three years.

Acute Disease↗
PubMed1996

The evolution of today's hospital emergency departments--current problems and challenges.

The announcement of the National Heart Attack Alert Program by the National Heart, Lung and Blood Institute in June of 1991 prompted leaders of the Florida Chapter of the American College of Cardiology to develop a statewide program to reduce the morbidity and mortality from acute myocardial infarctions within Florida. It became apparent that the success of such a program would require the prompt institution of thrombolytic agent or other revascularization procedures in appropriate patients. No longer could the decision regarding institution of therapy await discussion by telephone and/or the arrival at the emergency department (ED) of the patient's primary care physician or cardiologist. Efforts to establish appropriate protocols for therapy revealed that many of the 25,000 or more physicians currently staffing the 5,600 or so EDs in this country were moonlighting residents or practitioners from a variety of specialties or subspecialties with limited or no formal EM training. Furthermore, it was learned that there were in the entire country only about 800 postgraduate, year-one Council for Graduate Medical Education accredited training positions. There were only 21 such training positions in the entire state of Florida. The reasons for these deficiencies are discussed and a challenge to correct this person power crisis is issued, not principally to the leadership of EM, but to the entire medical profession.

Certification↗