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 172,036 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The hemodynamic effects of propofol-fentanyl and isoflurane-fentanyl anesthesia during the prebypass period were compared in 42 patients undergoing coronary artery bypass grafting (CABG) and 22 patients undergoing valve replacement (VR) for stenotic lesions. Anesthesia was induced with fentanyl, 25 micrograms/kg, and pancuronium, 0.1 mg/kg, and was maintained with a propofol infusion commenced at 4 mg/kg/h (range 1 to 10 mg/kg/h) or with isoflurane commenced at 1% (range 0 to 2%). Additional fentanyl, 7.5 micrograms/kg, was given before sternotomy. Hemodynamic measurements were made before induction of anesthesia and at various times in the prebypass period. In the VR group, there were no significant differences between the two anesthetics in any hemodynamic variables during the study. Significant decreases (P < 0.05) in mean arterial pressure (MAP 14%), left ventricular stroke work index (LVSWI 29%), and stroke volume index (SVI 24%) occurred after 15 minutes of propofol anesthesia in the CABG group. With isoflurane MAP was well maintained with reductions in LVSWI and SVI of 22% and 20%, respectively. Isoflurane was, however, associated with a significant increase in heart rate (HR) in the CABG group (P < 0.05), whereas no significant change in HR occurred in CABG or VR patients receiving propofol. With both techniques there were no significant changes in right-sided or left-sided filling pressures or in systemic vascular resistance index in the CABG or VR groups, except for a decrease in pulmonary artery occlusion pressure in the propofol VR group and isoflurane CABG group at the time of aortic cannulation. Propofol produced similar hemodynamic changes in the CABG and VR groups. Both anesthetic techniques caused myocardial depression and effectively controlled the autonomic responses to sternotomy in both groups. The study suggests that propofol-fentanyl anesthesia is an acceptable technique for CABG surgery and for VR in patients with stenotic valvular heart disease.
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PMID:Propofol-fentanyl anesthesia: a comparison with isoflurane-fentanyl anesthesia in coronary artery bypass grafting and valve replacement surgery. 806 Dec 62

In all cases of valvular heart disease one should avoid heavy premedications. This will ensure that the balance between preload and afterload is maintained and will avoid respiratory depression which may aggravate pulmonary hypertension. Agents which depress the myocardium should be avoided (an opiate technique is preferable to a technique based on volatile agents). Agents which cause a tachycardia should be avoided. Controlled ventilation is safer than spontaneous ventilation. Appropriate monitoring is essential in every case.
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PMID:Valvular heart disease: Anesthetic considerations in non-cardiac surgery. 828 43

Treadmill and clinical data were gathered prospectively on consecutive patients who underwent exercise testing for evaluation for coronary artery disease in a 1,200 bed Veterans Affairs Medical Center. From 3,609 men referred for exercise testing from 1984 to 1990, 3,134 patients remained after excluding those with significant valvular heart disease and those with prior coronary artery bypass surgery. Of these, 588 were selected for clinical reasons to undergo cardiac catheterization within 3 months of evaluation leaving 2,546 who were not selected. Over 3 years, there were 158 cardiovascular deaths, 99 nonfatal myocardial infarcts and 183 patients who underwent coronary artery bypass surgery. In the total population, the Cox proportional-hazards model demonstrated the following characteristics to be statistically significant independent predictors of time until cardiovascular death: a history of congestive heart failure and/or taking digoxin, exercise-induced ST depression, the change in systolic blood pressure during exercise, and exercise capacity in METs. Using the Cox model coefficients to weight the variables, a simple score (the Veterans Affairs Prognostic Score) was constructed based on these items. Average annual cardiovascular mortality was plotted against the score enabling its estimation for any given patient. In the subgroup selected for cardiac catheterization (n = 588), the mean score was greater, consistent with a poorer prognosis, compared with the total population; 53% (n = 312) had a score < -2 associated with an annual mortality < 2%. Thus, in over half of the patients selected for catheterization, the catheterization was unnecessary if performed to lessen their chance of cardiovascular death, since no intervention could improve their prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Prediction of atherosclerotic cardiovascular death in men using a prognostic score. 829 34

After the development of monophasic combined oral contraceptives (COCs), containing a fixed dose of estrogen and progestogen, biphasic and triphasic COCs were introduced in the 1980s; in these the dose of ethinyl estradiol and progestogen changes during the pill cycle. In the so-called every day pills, the 21 pills of active steroid combination are followed by 7 inactive pills containing starch, iron, or bran. Method failures of OCs are among the lowest ranging from 0.2-1/100 woman-years. User failures can be as high as 6.2/100 women-years. The individual difference in peak plasma levels of estrogens in women taking identical OCs can be 10-fold. Conditions that affect the bioavailability of contraceptive steroids are: 1) drug interaction (vitamin C, drugs that induce liver enzymes, and antibiotics); 2) vomiting; 3) vegetarianism; 4) missing pills; and 5) malabsorption. Metabolic effects of COCs pertain to carbohydrate metabolism, lipid metabolism, hemostasis, and vitamins. Prescribing of COCs involves counseling clients about contraindications to COCs, starting routines, and the pill-free interval, as well as follow-up and monitoring, the problem of missing pills, and selection criteria for OC use. Medical conditions in which COC use requires special consideration are sickle cell disease, trophoblastic disease, HIV disease, gallstones, epilepsy, valvular heart disease, oligomenorrhea/amenorrhea, inflammatory bowel disease, and surgery. Side effects of COCs may include depression, nausea, vomiting, headaches, urinary tract infection, and lower genital tract infections. 6 months after stopping the OC 1% of users become amenorrheic. Many of the common causes of amenorrhea, such as weight loss amenorrhea and polycystic ovarian disease, may be treated with the COC until the couple desires to have a baby. The new progestogens desogestrel, norgestimate, and gestodene are highly selective compared to first and second generation progestogens.
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PMID:Combined oral contraceptives: acceptability and effective use. 832 4

The objective of this report is the development of a population-specific prediction rule based on clinical and exercise test data that would estimate the risk of cardiovascular death in patients selected for cardiac catheterization. Prospective data and follow-up information were obtained from patients who underwent cardiac catheterization soon after clinical assessment and exercise testing. Males (n = 588) referred for evaluation of coronary heart disease from 1984 to 1990 were selected after exclusion of patients with significant valvular heart disease and patients with prior cardiac surgery. Half had a prior myocardial infarction and half complained of typical angina pectoris. All patients performed a treadmill test and were selected for clinical reasons to undergo coronary angiography within 3 months. Over a mean follow-up period of 2.5 years (+/- 1.4 years), there were 39 cardiovascular deaths and 45 nonfatal myocardial infarctions. The Cox proportional hazards model demonstrated the following characteristics to be statistically significant independent predictors of time until cardiovascular death: history of congestive heart failure (hazards ratio of 4), ST depression on the resting ECG (hazards ratio of 3), and a drop in systolic blood pressure below the resting value during exercise (hazards ratio of 5). Exercise-induced ST depression was not associated with either death or nonfatal myocardial infarction. A simple score based on one item of clinical information (history of congestive heart failure), a resting ECG finding (ST depression), and an exercise test response (exertional hypotension) stratified our patients for 4 years after testing from 75% with a low risk (annual cardiac mortality rate of 1%), 17% with a moderate risk (annual mortality rate of 7%), and 1% with a high risk (annual cardiac mortality rate of 12%, with a hazards ratio of 20 and 95% confidence interval from 6 to 70X). It was concluded that the variables available from the usual noninvasive workup of patients with known or suspected coronary artery disease enable prediction of risk of cardiovascular death. Three quarters of those usually undergoing cardiac catheterization can be identified by simple noninvasive variables as being at such low risk that invasive intervention is unlikely to improve prognosis.
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PMID:Prediction of cardiovascular death by means of clinical and exercise test variables in patients selected for cardiac catheterization. 849 16

Electrocardiographic (ECG) and echocardiographic examinations and 24-h ECG Holter monitoring were carried out in 100 patients (age < 65 years) with rheumatoid arthritis (RA) of stages II-IV according to Steinbrocker's criteria. One hundred patients with osteoarthrosis, spondyloarthrosis and painful shoulder matched for age, sex and body surface area constituted the control group. All patients with myocardial infarction, hypertension, rheumatic fever or a history of diabetes were excluded. Cardiac involvement, evaluated by echo-Doppler cardiography, 24-h ECG Holter monitoring and an ECG at rest, occurred in 52 (52%) patients with RA and in 23 (23%) control group patients (p < 0.0005). In the RA group ECG examination, 1 mm ST depression in at least two consecutive leads was observed more frequently, and occurred statistically more frequently for the highest stage of RA according to Steinbrocker's criteria, highest level of functional index and longer duration of disease. The 24-h Holter ECG monitoring did not show any differences in frequency of rhythm disorders between the RA group and the control group. However, silent myocardial ischaemia episodes appeared more often in the RA group. An ECG examination revealed more cases of valvular heart disease, especially mitral insufficiency, in RA patients than in the control group. A mitral valve prolapse was noted in 6% of patients and a pericardial effusion in 4% of patients. Patients with RA were noted to have a larger diastolic left ventricular diameter and aortic root diameter, and smaller ejection fraction, mean velocity of circumferential fibre shortening and fractional shortening. The results of the examinations show that RA is associated with cardiac involvement in a significant proportion of cases.
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PMID:Echocardiographic findings, 24-hour electrocardiographic Holter monitoring in patients with rheumatoid arthritis according to Steinbrocker's criteria, functional index, value of Waaler-Rose titre and duration of disease. 980 80

This review summarizes the neurochemical, therapeutic and adverse effects of serotonin (5-HT) releasing agents. The 5-HT releaser (plus minus)-fenfluramine is composed of two stereoisomers, (+)-fenfluramine and (minus sign)-fenfluramine, which are N-de-ethylated to yield the metabolites, (+)-norfenfluramine and (minus sign)-norfenfluramine. Fenfluramines and norfenfluramines are 5-HT transporter substrates and potent 5-HT releasers. Other 5-HT releasing agents include m-chlorophenylpiperazine (mCPP), a major metabolite of the antidepressant drug trazodone. Findings from in vitro and in vivo studies support the hypothesis that fenfluramines and mCPP release neuronal 5-HT via a non-exocytotic carrier-mediated exchange mechanism involving 5-HT transporters. (+)-Norfenfluramine is a potent 5-HT(2B) and 5-HT(2C) receptor agonist. The former activity may increase the risk of developing valvular heart disease (VHD), whereas the latter activity is implicated in the anorectic effect of systemic fenfluramine. Anorectic agents that increase the risk of developing primary pulmonary hypertension (PPH) share the common property of being 5-HT transporter substrates. However, these drugs vary considerably in their propensity to increase the risk of PPH. In this regard, neither trazodone nor mCPP is associated with PPH. Similarly, although some 5-HT substrates can deplete brain 5-HT (fenfluramine), others do not (mCPP). In addition to the established indication of obesity, 5-HT releasers may be helpful in treating psychiatric problems such as drug and alcohol dependence, depression and premenstrual syndrome. Viewed collectively, it seems possible to develop new medications that selectively release 5-HT without the adverse effects of PPH, VHD or neurotoxicity. Such agents may have utility in treating a variety of psychiatric disorders.
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PMID:Serotonin releasing agents. Neurochemical, therapeutic and adverse effects. 1188 73

Oxygen transport, its metabolic maintenance and immune status were studied in 17 patients with congenital valvular heart disease (CVD) having compensated (n = 8, group 1) and decompensated (n = 9, group 2) defects of hemodynamics. CVD patients with decompensated central hemodynamics and progressing hypoxia had impaired compensatory rearrangement of oxygen transport system. Accumulation of intracellular lactate, low activity of basic energetic cycles of blood cells most evident in decompensated CVD was observed in both the groups. In conditions of severe energy-structural deficiency and impaired function of oxygen transport systems, CVD patients develop secondary immune deficiency presenting with depression of basic immunoregulatory subpopulations of T- and B- cellular immunity (CD2, CD3, CD4, CD5, CD8, CD16, CD22).
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PMID:[Oxygen transport and immune status in patients with congenital valvular heart disease]. 1208 80

A variety of drugs release serotonin (5-HT, 5-hydroxytryptamine) from neurons by acting as substrates for 5-HT transporter (SERT) proteins. This review summarizes the neurochemical, therapeutic, and adverse actions of substrate-type 5-HT-releasing agents. The appetite suppressant (+/-)-fenfluramine is composed of (+) and (-) isomers, which are N-de-ethylated in the liver to yield the metabolites (+)- and (-)-norfenfluramine. Fenfluramines and norfenfluramines are potent 5-HT releasers. (+/-)-3,4-Methylenedioxymethamphetamine ((+/-)-MDMA, "ecstasy") and m-chlorophenylpiperazine (mCPP) are substrate-type 5-HT releasers. Fenfluramines, (+/-)-MDMA, and mCPP release neuronal 5-HT by a common non-exocytotic diffusion-exchange mechanism involving SERTs. (+)-Norfenfluramine is a potent 5-HT(2B) and 5-HT(2C) receptor agonist. The former activity may increase the risk of valvular heart disease, whereas the latter activity is implicated in the anorexic effect of systemic fenfluramine. Appetite suppressants that increase the risk for developing primary pulmonary hypertension (PPH) are all SERT substrates, but these drugs vary considerably in their propensity to increase this risk. For example, fenfluramine and aminorex are clearly linked to the occurrence of PPH, whereas other anorectics are not. Similarly, some SERT substrates deplete brain tissue 5-HT in animals (e.g., fenfluramine), while others do not (e.g., mCPP). In addition to the established indication of obesity, 5-HT releasers may help treat psychiatric disorders, such as drug and alcohol dependence, depression, and premenstrual syndrome. Viewed collectively, we believe new medications can be developed that selectively release 5-HT without increasing the risk for adverse effects of valvular heart disease, PPH, and neurotoxicity. Such agents may be useful for treating a variety of psychiatric disorders.
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PMID:Therapeutic and adverse actions of serotonin transporter substrates. 1216 29

For many years, the severity of valvular aortic stenosis (AS) was evaluated mainly on the basis of cardiac catheterization. In many centers, the handy peak-to-peak transvalvular pressure difference or 'peak-to-peak gradient' in relation to left ventricular function was used as a crucial feature in taking a decision regarding valve substitution. In a prospective study during the period 1994-1997, 150 consecutive patients with AS were examined systematically using cardiac catherization as well as transthoracic (TTE) and transesophageal echocardiography. The study was performed in order to compare the diagnostic accuracy and reproducibility of the three modalities with the purpose of improving our evaluation strategy. We found that the three methods were able to determine the aortic valve area with similar accuracy and reproducibility. The data thus support earlier papers and the currently recommended strategy of managing most patients on the basis of TTE since this approach is more rapid and gentle to the patients. In accordance with the past policy of our department, however, considerable weight was put on the invasive data during the study period. Thus, 12 patients with invasive peak-to-peak gradient <50 mm Hg and no severe depression of left ventricular function were not offered valve replacement, despite symptoms and significant valve area reductions. At 2.5 years of follow-up, 6 had died, 3 of severe heart failure, 2 while awaiting scheduled valve replacement, and 1 during aortocoronary bypass surgery. Another 3 patients later experienced further symptom progression and underwent successful aortic valve replacement. In the remaining 3 patients, all free from coronary stenoses and other valvular heart disease than AS, heart failure symptoms had worsened considerably during continued medical therapy. In conclusion, we do not recommend consideration of the peak-to-peak gradient in the process of deciding whether or not AS patients should receive valve replacement. A low peak-to-peak gradient does not exclude severe AS, even in the presence of preserved left ventricular function.
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PMID:Aortic valve stenosis: fatal natural history despite normal left ventricular function and low invasive peak-to-peak pressure gradients. 1533 24


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