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Query: UMLS:C0018799 (heart disease)
 34,133 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The evaluation and management of heart disease in patients about to undergo noncardiac surgery begins with a careful history and physical examination, including an assessment of clinical risk for perioperative myocardial infarction and/or death. Patients can be categorized into major, intermediate, minor or low clinical risk groups, based on clinical markers such as past myocardial infarction, congestive heart failure, angina or diabetes. Additional evaluation includes estimation of surgery-specific risk, prior coronary evaluation and/or revascularization, and level of functional capacity. Based on these parameters, physicians can decide to engage in further noninvasive testing to assess left ventricular function and/or risk of perioperative ischemia in a small, selected group of patients. Rarely, patients may meet criteria for perioperative coronary revascularization followed by noncardiac surgery. Perioperative medical therapy relies heavily on the use of beta blockers. Postoperative cardiac surveillance must be tailored to the individual patient. The use of pulmonary arterial catheters, the type of anesthesia and the assessment of long-term cardiac risk are also discussed in this summary of the ACC/AHA Guidelines.
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PMID:Surgical patients with heart disease: summary of the ACC/AHA guidelines. American College of Cardiology/American Heart Association. 930 74

The fiftieth anniversary of the ACC and the end of the twentieth century are arbitrary points in time, yet they seem to coincide with a true watershed. The last 50 years have brought a rush of new techniques and understandings that have, for the first time, given cardiovascular specialists real tools to prevent and fight cardiovascular disease. Only now, for the first time, has science begun to understand exactly what happens when plaque forms in an artery, when heart muscle fibers cross-link and weaken, when an atrial chamber fibrillates, and when heart muscle cells die en masse after a heart attack. We are beginning to track down the actual chemical, mechanical, and electrical pathways by which the heart is damaged or dies. When we can interfere with those pathways and stop the chain of events, we will have defeated heart disease. Imagination is rapid, but progress is often both uncertain and slow because of the many constraints of cost, regulation, and time needed to test and evaluate new developments. Yet we can now foresee a future in which medical science might actually defeat cardiovascular disease the way it has defeated polio, smallpox, and other serious scourges of the past.
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PMID:Technological advances and the next 50 years of cardiology. 1075 73

The aim of this study was to evaluate ventricular arrhythmias occurring in recipients of the InSync ICD for the primary and secondary prevention of sudden death. The InSync ICD was implanted in 142 patients (128 men; mean age 65 +/- 10 years) with heart failure (mean NYHA functional Class 3.0 +/- 0.7) and wide QRS (mean 159 +/- 33 ms). The underlying etiology was ischemic in 55%, idiopathic in 33%, and valvular or hypertensive cardiomyopathy in 12% of patients. The numbers of arrhythmic episodes/100 patient-months was computed with their 95% CI, assuming a Poisson distribution. Implants were performed in 48 (34%) patients who did not have an ACC/AHA guidelines Class I indication for ICD therapy. A total of 104 patients were compliant for follow-up visits. During a 9-month median (range 0.1-24) follow-up of 104 compliant patients, 19 experienced a total of 94 ventricular arrhythmias, all successfully interrupted or self-terminated, with a median number of two separate episodes, corresponding to a rate of 10 episodes/100 person-month (95% CI 8-12). A rate of 12 episodes/100 person-months (95% CI 10-15) was measured in the subgroup of patients with ACC/AHA class I indications, versus two episodes/100 person-months (95% CI 1-5) in the remainder of the population. Among 12 deaths, 9 were due to heart failure, 1 to a non-cardiovascular cause, and 2 to unknown causes. The implantation of ICD in heart failure patients has been prominently extended to primary prevention. Patients without standard ICD indications experienced life-threatening arrhythmic events. The impact of ICD combined with cardiac resynchronization therapy on arrhythmic profile, mortality, and costs in this subgroup of patients need to be more precisely studied, with a particular focus on the various types of underlying heart disease.
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PMID:Cardiac resynchronization and implantable cardioverter defibrillator therapy: preliminary results from the InSync Implantable Cardioverter Defibrillator Italian Registry. 1268 1

Despite the publication of the American Heart Association/American College of Cardiology (AHA/ACC) "Guide to Preventive Cardiology for Women" primary care screening and treatment of women at risk for coronary heart disease risk is not optimal. The purpose of this article is to apply a framework of physician behavior to describe specific challenges in implementing clinical practice guidelines for women's cardiovascular health in the primary care setting. Specifically, we illustrate 1) underlying barriers to adherence, 2) attempts and interventions to overcome these barriers, and 3) future areas of research to improve physician adherence to guidelines for the prevention and treatment of heart disease in women.
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PMID:Physician adherence to preventive cardiology guidelines for women. 1367 5

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. It is common in the elderly and those with structural heart disease. Clinical classification can be helpful in treatment decisions and the most widely accepted classification scheme (first episode, recurrent paroxysmal, recurrent persistent, permanent) is found in the ACC/AHA/ESC guidelines. The pathophysiology of AF remains unclear at this time. It is unlikely that a single pathophysiology is operative in all or even a majority of cases. Therapies to be considered for AF include prevention of thromboembolism, rate control, and restoration and maintenance of sinus rhythm. These therapies and specific treatments for these purposes are discussed under these headings, including a section on the relative merits of the rate control and rhythm control strategies. Risk stratification is a fundamental part of the treatment for thromboembolism. When risk warrants treatment, prevention of thromboembolism is achieved either pharmacologically with aspirin, or with warfarin or new agents like ximelagatran, or by nonpharmacological approaches. Schema to assist in risk stratification and selection of appropriate antithrombotic therapy are provided. Recent trials comparing the strategy of rate control to the strategy of rhythm control failed to demonstrate that the rhythm control approach is superior to the rate control approach in patients and therapies studied so far. Rate control is an acceptable primary line of therapy in many patients, particularly the elderly with persistent AF who are not highly symptomatic. However, the risk and benefit of each treatment modality should be individualized according to the patient circumstances and comorbidity. Algorithms to help individualize which of the two strategies to use are provided. There are a number of pharmacologic and nonpharmacologic therapies available for rhythm management of AF. Pharmacologic cardioversion is an alternative to electrical cardioversion for recent onset AF but the latter is preferred for persistent AF. Current drug therapy to maintain sinus rhythm is neither highly effective nor completely safe. An algorithm to guide selection of the most appropriate antiarrhythmic drug for an individual patient is provided. Nonpharmacologic therapies for maintenance of sinus rhythm include surgery, radiofrequency ablation, devices, and hybrid (combination) therapies. Much remains to be learned about the role and application of such therapies. Pharmacologic heart rate control can be achieved for most patients with available agents and, when it cannot, there are effective nonpharmacologic therapies. A few specific situations in which AF occurs and for which there are some special considerations are described.
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PMID:Management of atrial fibrillation. 1577 90

The endothelins are peptides with vasoconstricting and growth-promoting properties. Endothelin-1 (ET-1) is known with its direct positive inotropic and chronotropic effects on isolated heart and with growth effects. The aim of this pilot study was to investigate the frequency distribution of the common polymorphism of the ET-1 gene and its possible relation with hemodynamic consequences of malignant ventricular arrhythmias in patients with structural heart disease. We studied 26 consecutive patients with malignant ventricular arrhythmias and implantable cardioverterdefibrillators with a mean age of 62.7 +/- 12.2 years and a mean left ventricular ejection fraction of 0.37 +/- 11.0. Taq polymorphism of ET-1 was detected using our original polymerase chain reaction method. The polymerase chain reaction product with a length of 358 basepairs (bp) (primers 5'-CAA ACC GAT GTC CTC TGT A-3' and 5'-ACC AAA CAC ATT TCC CTA TT-3') in its non-mutated form contains a target sequence for TaqI restrictive enzyme, while a mutated product loses this cleavage site. Of 26 patients, nine (34%) had recurrent palpitations and eight (30.8%) had syncopes during their malignant arrhythmias. Nineteen patients were given amiodarone after implantable cardioverter-defibrillator insertion and seven were not treated with amiodarone. Fifteen patients had (++), 11 (+-) and 0 (- -) ET-1 genotype. The risk for syncopes was associated with the (++) genotype of the ET-1 gene (P = 0.01). Patients receiving amiodarone had significantly higher frequency of the (++) genotype (P = 0.011). All our results indicate that the presence of the ET-1 genotype (++) in patients with structural heart disease, severe left ventricular dysfunction and malignant ventricular arrhythmias increases the risk for these patients of hemodynamic collapse during these arrhythmias.
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PMID:Endothelin-1 gene polymorphism in patients with malignant arrhythmias. 1583 69

Untreated or palliated congenital heart disease has the strong impact on the outcomes of surgery for non-cardiovascular disease that accrues with age. However, excellent guidelines have not been published yet that provide ideal information and expert opinion for patients and doctors in assessing adult congenital heart disease (ACHD). In the global risk assessment for such a condition, American College of Cardiology--American Heart Association (ACC/AHA) guidelines can be helpful although developed exclusively from populations with acquired heart disease. The first necessity is to clarify the diagnosis The second is preoperative hemodynamic assessment according to the specific physiology and anatomy. The third is to evaluate the intensity of expected hemodynamic stress by proposed operation. The last is to elucidate co-morbid conditions. In addition to global risk assessment, Risk factors unique to ACHD must be carefully considered. Under complete assessment of these risk factors by the staff who have sufficient experience or training in the management of ACHD, the optimal, effective and meticurous cares can be provided to patients with ACHD encountered at noncardiac surgery.
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PMID:[Clinical information and management in patients with adult congenital heart disease undergoing non-cardiac surgery]. 1593 50

Physicians are frequently concerned with the management of the surgical risk in patients with heart disease requiring non cardiac surgery. A preoperative evaluation helps to assess the cardiac risk for the planned surgery and helps to take measures to reduce that risk. We summarize the essentials in evaluating patients with coronary artery disease, valvular heart disease, arterial hypertension, arrhythmias, permanent pacemaker bearers, and those with congestive heart failure in order to prevent cardiac complications during the required surgery. Special attention has been given to the functional capacity, cardiac risk present, presence or absence of left ventricular dysfunction and the institution of protective measures. The usefulness of the ACC AHA guidelines has been summarized.
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PMID:Evaluation of cardiovascular risks for non cardiac surgery. 1659 70

Management of patients with atrial fibrillation in clinical practice represents a major challenge. The 2001 ACC/AHA/ESC Atrial Fibrillation Guidelines have gained wide acceptance but recent advances have required their revision in 2006. Large strategy trials comparing rhythm control to rate control using drug therapy has shown no difference in terms of major endpoints including mortality. The reason suggested by substudy analysis was that the benefits of sinus rhythm obtained with antiarrhythmic agents were offset by their side-effects. The 2006 revised Guideline version in terms of management strategy does not differ significantly from the 2001 version as both rhythm control and rate control strategies were considered acceptable. The selection of an antiarrhythmic agent is still based on the presence and the type of underlying heart disease as the fruit of a consensus more than on evidence in a safety first approach. The only difference is that class Ia agents were deleted from the treatment algorithm. Catheter ablation techniques represent one of the major developments in recent years in the management of AF patients. The Guidelines recommend catheter ablation as a second line therapy in every branch of the therapeutic flow chart. In this respect, the 2006 version of the Guidelines although consistent with current practice is not evidence-based as randomized trials comparing ablative techniques to conventional management in AF are still lacking. Furthermore, the paroxysmal form and the persistent or chronic forms are not differentiated as for the persistent and long-standing AF the results of catheter ablation are less convincing. Catheter ablation techniques are complex and carry the risk of recurrences requiring a repeat operation in 20-40% of cases and the risk of serious complications that may be life-threatening if not appropriately detected and managed. Atrial fibrillation identifies a subset of patients at high risk of stroke. The 2006 Guidelines have stratified the stroke risk into three group levels in order to better define the group for whom oral anticoagulation with warfarin is mandatory in the absence of contra-indication. In this regard, the 2006 Guideline version represents a helpful improvement.
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PMID:Current atrial fibrillation guidelines and therapy algorithms: are they adequate? 1897 67

The appropriate progression of diagnostic testing for acute angina has been the topic of several recommendations by the American College of Cardiology and American Heart Association (ACC/AHA). We measured how frequently electrocardiography (ECG) is provided as the initial cardiac diagnostic test, as recommended for patients with new angina. Using an insurance database representing 2% of the U.S. adult population, we identified patients undergoing a new cardiac diagnostic process for angina. Rates of initial ECG were stratified by age, gender, co-morbid disease, and care setting. Of 4.4 million patients, 18,139 met the entry criteria by presenting with anginal symptoms for testing. A substantial portion (35%, 95% confidence interval [CI] 34% to 35%) did not receive the initial ECG recommended by expert guidelines. Patients treated in emergency departments received an initial ECG more frequently (91%, CI 90% to 92%) than patients tested in outpatient settings (61%, CI 60% to 62%; risk ratio [RR] 0.67, CI for RR 0.65 to 0.68) or in inpatient hospital settings (34%, CI 32% to 37%; RR 0.38, CI for RR 0.36 to 0.40). Slightly lower rates of initial ECG were observed in men (RR 0.93 vs women, CI for RR 0.91 to 0.95) and patients over 64 years (RR 0.93 vs younger patients, CI for RR 0.91 to 0.95). Total diagnostic costs averaged $954 when testing began with the recommended ECG versus $1,233 when testing did not. In conclusion, ECG is not universally obtained as the initial test for patients presenting with anginal symptoms despite evidence-based recommendations for such use. Clinicians should be aware that suboptimal use of ECG in certain settings may hinder investigations of heart disease.
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PMID:Frequency of electrocardiographic recordings in patients presenting with angina pectoris (from the Investigation of National Coronary Disease Identification). 1916 81


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