Management Of Cardiac Patients Research Articles

Infarto agudo de miocardio asociado al consumo de sildenafil. Aportación de caso y revisión de la literatura

Erectile dysfunction affects more than 30 million men in The United States. Since the FDA approved the use of Sildenafil, prescription of this medication has been raising. Adverse events of Sildenafil includes: fatigue, dyspnea, and hypotension. Reported adverse cardiac events associated with the medication use include myocardial infarction, ventricular tachycardia, angina and death, raising concerns about the safety of this agent in patients with coronary artery disease. Published guidelines regarding the management of cardiac patients with erectile dysfunction suggest that Sildenafil may be hazardous in patients with ischemic heart disease. In patients using Sildenafil, myocardial infarctions have been reported to the Food and Drug Administration. Now, we report a patient with myocardial infarction after taking 100 mg of Sildenafil without sexual activity.

Vascular surgery critical care: Perioperative cardiac optimization to improve survival

To review the literature on perioperative cardiac management of patients who are scheduled to undergo vascular surgery. MEDLINE- and PubMed-based review of literature published from 1965 to 2005. Perioperative cardiac events (myocardial infarction, heart failure) remain the leading cause of morbidity and mortality in vascular surgery patients. Existing guidelines allow physicians to cost-effectively streamline preoperative cardiac risk assessment and stratification. Perioperative optimization of volume status and cardiac function and the routine use of perioperative beta-blockers can significantly improve outcomes after major vascular surgery. Perioperative addition of statins to beta-blockers in high-risk patients undergoing vascular surgery merits further evaluation. Preoperative coronary revascularization should be restricted to patients with unstable cardiac symptoms.

What is the Prognostic Value of Myocardial Perfusion Imaging Using Rubidium-82 Positron Emission Tomography?

The objective was to determine the prognostic value of rubidium-82 (82Rb) positron emission tomography (PET) myocardial perfusion imaging (MPI). 82Rb PET MPI accurately diagnoses coronary artery disease (CAD). However, there are limited data evaluating its prognostic value. Follow-up (3.1 +/- 0.9 years) was obtained in 367 patients who underwent dipyridamole 82Rb PET MPI. Patients were divided into groups based on their summed stress score (SSS): group I, normal (<4); group II, mild (4 to 7); and group III, moderate (8 to 11) to severe (> or =12). There were significant differences among patients in the 3 SSS groups for hard events (cardiac death and myocardial infarction [MI]) (p < 0.001) and total cardiac events (hard events, revascularization and hospitalization) (p < 0.001). The annual hard events rates were 0.4%, 2.3%, and 7.0% in the normal, mild, and moderate-severe groups, respectively. In adjusted survival models, 82Rb PET SSS was the strongest predictor of total cardiac events and a significant predictor of hard events. Among patients referred for PET after 99mTc single-photon emission computed tomography, the annual total event rate was higher with abnormal versus normal SSS on PET (15.2% vs. 1.3%, p < 0.001). In patients with obesity, the annual total event rate was 11.1% with an abnormal scan and 1.5% with a normal scan (p < 0.001). This study shows that 82Rb PET MPI has significant prognostic value for predicting cardiac events, including death and MI. It also seems to have prognostic value in patients whose diagnosis remains uncertain after single-photon emission computed tomography MPI and in obese patients. The prognostic value of PET MPI may improve the management of cardiac patients.

Haemodynamic instability after cardiac surgery: nurses’ perceptions of clinical decision‐making*

Cardiac surgical patients are distinguished by their potential for instability in the early postoperative period, highly invasive haemodynamic monitoring technologies and unique clinical presentations as a result of undergoing cardiopulmonary bypass. Little is known about nurses' perceptions of assuming responsibility for such patients. An understanding of nurses' perceptions may identify areas of practice that can be improved and assist in determining the adequacy of current decision supports. The aim of this study was to describe critical care nurses' perceptions of assuming responsibility for the nursing management of cardiac patients in the initial two-hour postoperative period. An exploratory descriptive study based on naturalistic decision-making. Thirty-eight nurses were interviewed immediately following a two-hour observation of their clinical practice. Content analysis and a systematic thematic analysis process called 'Framework' were used to analyse the interview transcripts. Nurses described their perceptions of managing patients in terms of how they felt about making decisions for complex cardiac surgical patients and in terms of how clinical processes unique to the admission phase impacted their decision-making. Nurses felt either daunted or stimulated and challenged when making decisions. Nurses identified handover from anaesthetists, settling in procedures and forms of collegial assistance as important processes that impacted their decision-making. Nurses' previous experiences with similar patients influenced how they felt about making decisions during the initial two-hour postoperative period, but did not alter their views about processes important for patient safety during this time. Feelings expressed by nurses in this study highlight the need for clinical supervision and appropriate allocation of resources during the immediate recovery period after cardiac surgery. Nurses identified ways to improve clinical processes that impacted their decision-making during the immediate recovery of cardiac surgical patients.

Reperfusion therapy

In this article Nick Castle explains that, with significant improvements being made to the emergency management of cardiac patients, emergency nurses should challenge and develop their clinical practice to ensure patients receive prompt and evidence based treatment.

REPORT: The Second Princeton Consensus on Sexual Dysfunction and Cardiac Risk: New Guidelines for Sexual Medicine

Erectile dysfunction (ED) is a highly prevalent disorder associated with a significant burden of illness. The prevalence and incidence of ED are strongly age-related, affecting more than half of men >60 years. The first Princeton Consensus Conference (Princeton I) in 1999 developed guidelines for safe management of cardiac patients regarding sexual activity and the treatment of ED. The second conference (Princeton II) was convened to update the recommendations based on the expanding knowledge base and new treatments available. This article reviews and expands on the Princeton II guidelines to address sexual dysfunction and cardiac risk. A consensus panel of experts reviewed recent multinational studies in safety and drug interaction data for three phosphodiesterase type 5 (PDE5) inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Erectile dysfunction is an early symptom or harbinger of cardiovascular disease, due to the common risk factors and pathophysiology mediated through endothelial dysfunction. Major comorbidities include diabetes, hypertension, hyperlipidemia and heart disease. Any asymptomatic man who presents with ED that does not have an obvious cause (e.g., trauma) should be screened for vascular disease and have blood glucose, lipids, and blood pressure measurements. Ideally, all patients at risk but asymptomatic for coronary disease should undergo an elective exercise electrocardiogram to facilitate risk stratification. Lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease, is literature-supported. The recognition of ED as a warning sign of silent vascular disease has led to the concept that a man with ED and no cardiac symptoms is a cardiac (or vascular) patient until proven otherwise. Men with ED and other cardiovascular risk factors (e.g., obesity, sedentary lifestyle) should be counseled in lifestyle modification.

Integrating Psychologic Approaches Into the Behavioral Management of Cardiac Patients

Despite increasing evidence that depression and other psychologic risk factors promote atherosclerosis and adverse cardiac events, practice guidelines for integrating psychologic considerations into the management of cardiac patients are currently lacking. This review explores how application of psychologic principles may help physicians to implement three basic approaches for improving the behavioral management of cardiac patients. The first is the identification and reduction of barriers to following behavioral recommendations, including the presence of negative mood states and other psychologic factors. Patients often self-manage negative moods through unhealthy behaviors such as smoking or eating. However, replacement of these behaviors with more health-promoting behaviors such as exercise and stress management techniques is often difficult and may require active assistance. Second, physicians should help provide patients with external support systems such as referral to support groups or telephone follow ups, when necessary. Such external supports, however, often require other approaches for long-term maintenance of new health behaviors. Third, a motivational literature suggests that physicians can promote patient self-management by formulating health goals in a manner that satisfies "basic psychologic needs" such as the needs for autonomy and competency. Satisfaction of these needs increases "vitality" (a positive state of energy and enthusiasm). Motivation can also be enhanced by creating an emotional attachment to health goals. A case example is provided to illustrate the application of these concepts in clinical practice, and future directions are discussed, including a potential healthcare model that could make the behavioral management of patients more feasible in cardiac practice.

Technology Insight: assessment of myocardial viability by delayed-enhancement magnetic resonance imaging

Myocardial viability is of established importance to the management of cardiac patients being considered for revascularization. Existing noninvasive imaging tests to examine myocardial viability, such as stress echocardiography and nuclear scintigraphy, are of recognized utility but are subject to intrinsic limitations. Over the past few years delayed-enhancement MRI (DE-MRI) has emerged as an alternative to traditional tests and for the first time allows direct visualization of the transmural extent of myocardial viability. In this paper we review the scientific data that underlie the use of DE-MRI in patients with ischemic heart disease. Progress in this area is largely the result of the development of a new MRI pulse sequence in the late 1990s, which improved the detection of necrotic and scarred myocardial tissue. Following this technical development, a series of detailed histologic comparisons in large animal models revealed that both acute and healed myocardial infarcts appeared as brighter (hyperenhanced) areas than viable regions, and that the effect is independent of contractile function. The resulting 'bright is dead' hypothesis has thus far proven of significant use in patients with ischemic heart disease. Data are now emerging which suggest that the DE-MRI technique also has important implications for patients with nonischemic forms of cardiomyopathy.

Perioperative Pain Management in the Cardiac Patient

Pain is the perception of an unpleasant sensation to warn the body of tissue injury. Nociceptors send stimuli to the central nervous system via neurons that enter the spinal cord via the dorsal horn. The signal is then processed, integrated, and relayed to higher centres for interpretation. Surgery stimulates pain pathways due to the tissue injury that it creates and in this way a neuroendocrine cascade is set into action as a protective mechanism by the body. Cardiac patients and patients with cardiac risk factors pose a special risk when undergoing surgery. They exist in a state of altered vascular responsiveness due to endothelial injury and chronic inflammation of the vasculature. The physiologic response to pain may put cardiac patients at risk for cardiac events in the perioperative period. More recent methods in pain control, such as epidural anaesthesia, can be used to decrease the risk of cardiac events in these patients. Pain transmission and analgesia will be explored in this paper. Furthermore, the current American College of Cardiology and American Heart Association Task Force guidelines on the management of cardiac patients undergoing noncardiac surgery as well as the literature published since the release of these guidelinte will be discussed.

Peak early diastolic mitral annulus velocity by tissue Doppler imaging adds independent and incremental prognostic value

ObjectivesThe aim of this study was to ascertain if left ventricular mitral annulus velocities measured by tissue Doppler imaging (TDI) are more powerful predictors of outcome compared with clinical data and standard Doppler-echocardiographic parameters. BackgroundTissue Doppler imaging of basal or mitral annulus velocities provides rapid assessment of ventricular long axis function. But it is not known if TDI-derived velocities in systole and diastole add incremental value and are superior to the standard Doppler-echocardiographic measurements as a predictor of outcome. MethodsThe study population consisted of 518 subjects, 353 with cardiac disease and 165 normal subjects who had full Doppler two-dimensional–echocardiographic studies with measurement of mitral inflow velocities in early and late diastole, E-wave deceleration time (DT), peak systolic mitral annular velocity (Sm) early and late diastolic mitral annular velocity (Em and Am) by TDI, early diastolic flow propagation velocity, and standard chamber dimensions. All subjects were followed up for two years. The end point was cardiac death. ResultsTissue Doppler imaging mitral annulus systolic and diastolic velocities were all significantly lower in the non-survivors (all p < 0.05) as was DT (p = 0.024). In the Cox model the best predictors of mortality were Em, Sm, Am, left ventricular ejection fraction, left ventricular mass, and left atrial diameter in systole (LADs). By backward stepwise analysis Em and LADs were the strongest predictors. After forcing the TDI measurements into the covariate model with clinical and mitral DT <0.16 s, Em provided significant incremental value for predicting cardiac mortality (p = 0.004). ConclusionsMitral annulus velocity measured by TDI in early diastole gives incremental predictive power for cardiac mortality compared to clinical data and standard echocardiographic measurements. This easily available measurement adds significant value in the clinical management of cardiac patients.

Rol del fisioterapeuta en el marco de la rehabilitación cardíaca

Therapeutic management of cardiac patient must be integrally achieved, acting on physical, psychological, social and familiar spheres of the subject and controlling risk factors. It is a group of interventions organized into a program, developed by several professionals and whose main goal is to provide social reinsertion, to increase quality of life and to decrease morbimortalityThe purpose of this paper is to show physiotherapeutic community the characteristics of a type-program in the cardiac rehabilitation context and from the physical therapy point of view, describing the role that physiotherapist plays there and justifying his participation in the multidisciplinary team.

Usefulness of dynamic multislice computed tomography of left ventricular function in unstable angina pectoris and comparison with echocardiography

For efficient cardiac patient management, a comprehensive noninvasive cardiac examination is desirable. Multislice computed tomography (CT) has the potential to assess coronary artery stenosis.1,2 Multislice CT may assess left ventricular (LV) function in addition, without the need for extra acquisitions. The purpose of the present study was to apply dynamic multislice CT for the assessment of regional wall motion and global cardiac function in patients with unstable angina, and to compare the results with conventional 2-dimensional echocardiography.

Initial Perioperative Care of the Cardiac Surgical Patient

Recently, changes in the management of cardiac patients have allowed earlier discharge from the cardiac recovery area and reduced hospital length of stay. These changes have been drien by a need to reduce the cost of cardiac surgery and imrove efficiency. This change has been both financially sucessful and safe for patients. To allow for this success, a joint effort is required between the departments of cardiac surgery and anesthesiology involving the preoperative, intraoperative and postoperative treatment of these patients. Through recogition of suitable candidates, modifications in anesthetic techique, and appropriate postoperative management, the goal of extubation within 6 hours of admission to the cardiac recovery area can be achieved. Changes in intraoperative and early postoperative management of cardiac surgical patients are discussed. Specific recovery models are reviewed with disussion of the parallel and integrated models. Methods of preicting prolonged extubation times and intensive care unit length of stay are also discussed. Initial management of the cardiac patient in the cardiac recovery area is presented with a more in-depth review of specific complications: stroke, atril fibrillation, blood loss, left ventricular dysfunction, and pulonary dysfunction.

ADVANCES IN CARDIAC ELECTROPHYSIOLOGY AND PACING

Significant advances have been made in the management of cardiac arrhythmias. New technology has enhanced the ability to understand and treat a variety of tachycardias. Excitement and caution surround ablative approaches for atrial fibrillation. The role of ICDs and class III antiarrhythmic drugs in the management of patients at risk for sudden cardiac death has been clarified. A new indication for cardiac pacing is evolving as a supplemental treatment for patients with refractory congestive heart failure. These and other advances provide numerous exciting options for management of cardiac patients.

The roles of gender, the menopause and hormone replacement on cardiovascular function.

Time for primary review 22 days. While it is recognised that gender differences exist in cardiovascular disease, it has only recently been appreciated that significant gender differences also exist in cardiovascular function. Ageing is associated with a different spectrum of cardiac and vascular maladaptations in women compared to men. These differences may contribute to poorer outcome in women affected by ischaemic disease compared to men as well as the higher prevalence of symptomatic cardiac failure seen in women. The most obvious gender-related difference in physiological ageing is the menopause in women. The relation of this ‘event’ to cardiovascular disease has generated much controversy, especially with respect to hormone replacement therapy in the management of cardiac patients. Controversy also exists in the role of declining androgen levels in men with age and the advisability of testosterone supplementation in men. This review will examine gender differences which become apparent due to ageing, as well as the specific effect of the menopause and hormone replacement on cardiac and vascular structure and function. It will also summarise the impact of these physiological and epidemiological differences on the expression of cardiovascular disease in men and women. Studies examining the role of gender and hormone withdrawal and administration in animal studies will also be summarised. Limitations in current research and recommendations for future areas of research are put forward. Because of the higher cardiac mortality in men compared to women until late in life [1], most early studies focused exclusively on that gender. Women have been excluded from research protocols during childbearing years and in old age because of co-morbidities [2]. Recently research emphasis has shifted in line with the recognition that cardiovascular disease remains the most prevalent illness affecting women and remains the most frequent cause of female death in most Western nations … * Corresponding author. Tel.: +44-171-351-8112; fax: +44-171-823-3392 peter.collins{at}ic.ac.uk

Textbook of Cardiovascular Medicine

Dr Topol’s Textbook of Cardiovascular Medicine is an excellent embodiment of the current era of evidence-based medicine. The editor, Dr Eric Topol, is a leader in the field of clinical trials in cardiovascular medicine, and this approach comes through in his textbook. As he states in the preface, his purpose is to bring forth currently available information from clinical trials to guide the management of cardiac patients. This textbook is an up-to-the-minute compendium of the new data available from clinical trials in cardiology today. Indeed, many of the figures included are from articles still in press or from trials that have been presented but not yet published. The presentation of the data is very clear and again is based on the trials. There are numerous figures and tables (between 20 and 40 per chapter) that help illustrate the data being discussed and also allow readers to quickly review …

Essentials of Cardiac and Thoracic Anaesthesia

This short book has been written to provide the essential core knowledge for SpRs. In addition, it is hoped that specialist nurses and technicians in the operating theatre and intensive care unit will be interested. The cardiac section is divided into five chapters. The first on assessment is very sound and includes the traditional and more recent risk scores, e.g. the Parsonnet score. There is a short and very relevant section on ‘fast tracking’. Echocardiography is increasing in use and, in future, anaesthetists will be expected to be competent in both its use and interpretation. The second and third chapters are concerned with the management of cardiac patients and could be described as ‘core essentials’, with emphasis on good techniques, monitoring, anaesthesia and analgesia. The chapter on cardiopulmonary bypass is extremely well done and well worth reading by anyone involved with cardiac anaesthesia. It is very informative and wide ranging. However, any drug doses for heparinisation should more correctly be described as regimens. The common postoperative complications are discussed and the additional advice for ‘fast tracking’ is an appropriate end of the first section. The same format is followed for thoracic anaesthesia which is generally considered to be more demanding. The pre-operative assessment is informative and discusses the interpretation of all the common results. The anaesthetic techniques include a short section on endobronchial tubes and the relevant checking procedures. The physiology that underpins one-lung anaesthesia is very useful as is the clinical management. The chapter on specific thoracic procedures is generally sound but I would disagree quite strongly with the cardiovascular monitoring recommended for mediastinoscopy. The final chapter on postoperative management deals with respiratory monitoring, chest drains and common complications. It culminates with a broad brush approach to the treatment of pain following thoracic surgery. It discusses, albeit in a few paragraphs, the current approach to the epidural space, which level and what to use. Not surprisingly, mixtures of opioid and local analgesic solution are the drugs of choice and it recommended that they are administered via a high lumbar route. I found this book easy to read and very informative. I was, however, disappointed with part of the chapter on specific thoracic procedures. The advice on vascular monitoring did seem to fly in the face of that generally accepted. Furthermore, the lack of a paragraph on the indication or otherwise for nasogastric tubes in cardiothoracic anaesthesia was equally disappointing. However, these criticisms apart, the book follows and meets the aims of the authors. The latter are to be congratulated in setting out what are complicated subjects in a concise, scientific and readable manner. As I am involved in cardiothoracic anaesthesia, I would most certainly buy this book. I would also urge trainees to read this book as it gives them a good grounding in these important disciplines.

Analytical performance of a monoclonal digoxin assay by dry chemistry on the Vitros 950

Digoxin assay in plasma/serum samples is used for therapeutic measurements as a guide to clinical management of cardiac patients. A thin dry film multilayer monoclonal immunoassay for digoxin, Vitros, was evaluated for analytical performance. The effect of digoxin-like immunoreactive substances (DLIS) was studied assaying plasma samples taken from 100 renal disease patients, 62 hepatic disease patients and 40 pregnant women not receiving digoxin. The Vitros digoxin assay was compared with the AxSym digoxin II assay using plasma samples from 180 patients treated with digoxin. The results revealed satisfactory precision and accuracy for therapeutic drug monitoring purposes: the coefficient of variation (CV%) was lower than 5%; results for dilutions were linear in the range 0.4-3.9 microlg/L and mean analytical recovery was 105%. Measurable DLIS concentrations were observed in 29% of hepatic disease patients and in 7% of renal disease patients with apparent digoxin concentration ranging from 0.4 to 0.75 microg/L. The incidence of DLIS was comparable to that observed with AxSym digoxin II. Comparative results from patient samples gave a regression line equation: Yvitros 950=0.96XAxym +0.14, r=0.89. The data revealed a mean difference of 0.09+/-0.26 microg/L significantly greater than zero (p=0.02). We concluded that Vitros digoxin assay for precision, accuracy and extent of DLIS interference may be a good method for therapeutic drug monitoring; care needs to be taken since assay results generated by Vitros and AxSym analysers are not necessarily interchangeable.

Nuclear cardiology: New developments and future directions

New developments in the field of nuclear cardiology include attenuation, scatter and depth resolution correction, newly designed gamma cameras, newer tracers, and newer stress agents. These developments, together with many new applications, are likely to continue to place nuclear cardiology in the mainstream of management of cardiac patients.

Preoperative Cardiac Management of Patients Undergoing Non Cardiac Surgery.

SummaryThe estimation of an individual patient’s “resistance” to major surgery has become an complex matter. Clinical parameters allow risk stratification in a large number of patients who are about to undergo noncardiac surgery. Low risk patients can be “cleared” for surgery. Moderate risk patients should undergo further testing. Exercise testing and pharmacological stress testing with myocardial perfusion imaging can refine risk estimation in these patients. This risk stratification is well backed by scientific data, although most of it is derived from studies in the same very high risk population, i.e. patients scheduled for vascular surgery. Less hard evidence exists when it comes to the management of the high-risk patient. Coronary bypass surgery should probably be reserved for those in whom additional indications for this procedure exist. The perioperative use of beta-blockers can possibly reduce operative risk. Data on perioperative monitoring and anesthetic technique are not yet convincing. The relative merits of various perioperative management strategies will remain uncertain until randomised trials are performed to evaluate the alternatives systematically.