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Query: UMLS:C0022116 (ischemia)
 91,303 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Approximately 20 to 40 percent of patients at high risk of cardiac-related morbidity develop myocardial ischemia perioperatively. The preferred approach to diagnostic evaluation depends on the interactions of patient-specific risk factors, surgery-specific risk factors, and exercise capacity. Stress testing should be reserved for patients at moderate to high risk undergoing moderate- or high-risk surgery and those who have poor exercise capacity. Further cardiovascular studies should be limited to patients who are at high risk, have poor exercise tolerance, or have known poor ventricular function. Medical therapy using beta blockers, statins, and alpha agonists may be effective in high-risk patients. The evidence appears to be the strongest for beta blockers, especially in high-risk patients with proven ischemia on stress testing who are undergoing vascular surgery. Many questions remain unanswered, including the optimal role of statins and alpha agonists, whether or not these therapies are as effective in patients with subclinical coronary artery disease or left ventricular dysfunction, and the optimal timing and dosing regimens of these medications.
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PMID:Preparation of the cardiac patient for noncardiac surgery. 1737 11

To clarify the participation of inducible NOS (iNOS) in the hypoxia-ischemia, we examined iNOS and its tetrahydrobiopterin co-factor in the cerebral cortex and plasma in a newborn-piglet model. We also investigated the role of hypothermia in iNOS expression and biopterin production. Male newborn piglets were ventilated 6% oxygen for 45 min. Their common carotid arteries were clamped during hypoxia. Then they were resuscitated with 30% oxygen (HI group). Piglets of the hypothermia group were treated as the HI group and their body was cooled to 35.5 degrees C after hypoxic-ischemic insults. Sham-treated piglets were also reserved. In the HI group, iNOS was present in neurons and macrophages of the cerebral cortex 12h after the insult. The concentrations of nitrite and nitrate were elevated in the cerebral cortex 12h after hypoxic-ischemic insults but the biopterin level was unchanged. The plasma biopterin concentration after the insult (377.9+/-78.7 nM) was five times higher than before the insult (80.1+/-4.3 nM); this level peaked 4h after the insult (604.8+/-200.9 nM) and only slightly decreased after 12h (445.9+/-57.8 nM). In the hypothermia group, no iNOS expression was observed 12h after the insult. The plasma biopterin concentration after the insult (464.2+/-92.3 nM) was similar to that in the HI group, but was suppressed by 4h of hypothermia (229.3+/-106.8 nM). In this study, neuronal iNOS expression and increase of NO production were found in the acute phase of hypoxia-ischemia. Brain biopterin did not increase in hypoxia-ischemia although plasma biopterin was five-fold elevated. The discrepancy may also affect hypoxic-ischemic organ damage.
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PMID:Biopterin in the acute phase of hypoxia-ischemia in a neonatal pig model. 1757 22

To examine the effects of hyperglycemia on a transient ischemia in the neonatal brain, neuropathological and biochemical evaluations were performed. In 10-day-old rats, brain ischemia was induced by permanent occlusion of the right external and internal carotid and subclavian arteries and the clamping of the left external and internal carotid arteries for 2h. The peritoneal injection of a 50% glucose solution (0.10 ml/15 g weight) 5 min before the induction of brain ischemia increased the plasma glucose concentration to 20-25 mmol/l during ischemia. It preserved brain tissue glucose levels at 1h of ischemia in the glucose-treated group, while tissue glucose was exhausted in the saline-injected group. Tissue lactate concentrations increased slightly at the end of the ischemic insult (6.7 mmol/kg) in the saline-injected group and remarkably (18.7 mmol/kg) in the glucose-treated group. Two distinct forms of ischemic neuronal change were found in this study: ischemic cell change and reactive neuronal change. A quantitative neuropathological assessment indicated that hyperglycemia significantly reduced the volume of ischemic cell change in the neocortex from 85% to 33%, but not that of reactive neuronal change (from 5.5% to 2.4%). These results indicated that hyperglycemia attenuated ischemic cell change, but not reactive neuronal change, in the neonatal rat brain and suggested that it reduced ischemic cell change probably because of reserved brain glucose.
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PMID:The effects of hyperglycemia on ischemic cell change and reactive neuronal change in neonatal rat brain following transient forebrain ischemia. 1782 22

Coronary artery disease (CAD) accounts for a large fraction of the morbidity, mortality, and cost of diabetes. Recognizing this, nearly 10 years ago the American Diabetes Association published a consensus recommendation that clinicians consider a risk factor-guided screening approach to early diagnosis of CAD in both symptomatic and asymptomatic patients. Subsequent clinical trial results have not supported those recommendations. Since the prior consensus statement, newer imaging methods, such as coronary artery calcium scoring and noninvasive angiography with computed tomography (CT) techniques, have come into use. These technologies, which allow quantitation of atherosclerotic burden and can predict risk of cardiac events, might provide an approach to more widespread coronary atherosclerosis screening. However, over this same time interval, there has been recognition of diabetes as a cardiovascular disease (CVD) equivalent, clear demonstration that medical interventions should provide primary and secondary CVD risk reduction in diabetic populations, and suggestive evidence that percutaneous coronary revascularization may not provide additive survival benefit to intensive medical management in patients with stable CAD. This additional evidence raises the question of whether documenting asymptomatic atherosclerosis or ischemia in people with diabetes is warranted. More data addressing this issue will be forthcoming from the BARI 2-D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. Until then, for patients with type 2 diabetes who are asymptomatic for CAD, we recommend that testing for atherosclerosis or ischemia, perhaps with cardiac CT as the initial test, be reserved for those in whom medical treatment goals cannot be met and for selected individuals in whom there is strong clinical suspicion of very-high-risk CAD. Better approaches to identify such individuals based on readily obtained clinical variables are sorely needed.
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PMID:Screening for coronary artery disease in patients with diabetes. 1790 30

Peripheral artery disease is one of the most prevalent conditions, and it frequently coexists with vascular disease in other parts of the body. Early diagnosis is important for improving the patient's quality of life and for reducing the risk of serious secondary vascular events such as acute myocardial infraction (AMI) or stroke. The best noninvasive measure for identifying the presence of occlusive arterial disease is the ankle-brachial index, which can also be used to indicate the prognosis of the affected extremity and to predict the likelihood of AMI during follow-up. Intermittent claudication in the lower limbs is the most common clinical presentation. The presence of critical ischemia (i.e., with rest pain or trophic changes) indicates the need for prompt revascularization because of the high risk of limb amputation. The more proximal the affected arterial segment, the better the outcome of the procedure. Endovascular treatment is usually reserved for lesions affecting multiple segments. It gives poorer results in occluded arteries. In extensive disease, conventional surgery is usually the best option.
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PMID:[Peripheral artery disease: pathophysiology, diagnosis and treatment]. 1791 54

Three cases of internal carotid artery (ICA) dissection due to trivial trauma were reported. A 14-year-old, previously healthy, girl developed left hemiparesis after jogging. MRI sh owed cerebral infarction in the right basal ganglia and the MR angiography (MRA) revealed luminal narrowing of the right ICA as well as pseudolumen at the origin of the right ICA. She was treated with antithrombotic therapy. Follow-up MRA demonstrated normal signal in the right ICA. A 23-year-old woman admitted to the hospital because of minor facial injury due to a traffic accident. Although she had no apparent symptom, follow-up CT, one day after presentation,. showed cerebral infarction in the right basal ganglia. Angiography showed diminished luminal diameter of the right ICA. She was treated with antithrombotic therapy and follow-up angiography showed reconstitution of normal lumina of the right ICA. A 34-year-old woman was referred to our hospital because of transient ischemic attack following swimming. Neurological examination was normal and MRI did not show any ischemic lesion. MRA revealed diminished signal in the left ICA as well as string and pearl sign at the origin of the left ICA. She was treated with antithrombotic therapy, and follow-up angiography showed normalization of the left ICA. Cervical ICA dissection due to trivial trauma usually appears as an eccentric tapered stenosis arising at the origin of the ICA and resolves with complete or excellent recovery in most cases. Surgical or endovascular treatment should be reserved for patients who have persistent symptoms of ischemia despite adequate antithrombotic treatment.
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PMID:[Three cases of internal carotid artery dissection due to trivial trauma]. 1808 May 18

Takayasu's arteritis is a rare disease that causes arterial inflammation with resulting stenosis or aneurysm of affected vessels. It primarily affects young females and has a predilection for the aorta, its primary branches, and the pulmonary arteries. Patients may present with symptoms of organ ischemia, such as stroke or claudication, or with signs of arterial stenosis, such as absent pulses or asymmetric blood pressures. Most patients require chronic immunosuppressive therapy to control inflammation. The foundation of therapy is glucocorticoids, which are often used in combination with other immunosuppressive agents, such as methotrexate, azathioprine, or mycophenolate mofetil. The goal of systemic therapy is to induce and maintain disease remission, often defined as the absence of new arterial lesions, lack of systemic symptoms, and ability to taper prednisone to less than 10 mg/d. Promising results have been seen with the use of agents directed against tumor necrosis factor in patients who have failed to maintain remission with standard therapies. Revascularization procedures such as percutaneous transluminal angioplasty (PTA) or bypass grafting are reserved for patients who have critical organ ischemia or severe extremity claudication. Bypass grafting has a lower restenosis rate than PTA and is the preferred method of restoring blood flow to affected organs. Frequent laboratory testing is recommended to monitor for drug toxicity and signs of disease relapse. At each clinic visit, physicians should auscultate for bruits over primary arterial branches and evaluate for asymmetry between arm and leg blood pressures. Biannual radiographic imaging with magnetic resonance or CT angiography is helpful to examine for evidence of new aortic aneurysms or arterial stenoses.
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PMID:Takayasu's arteritis. 1832 19

The authors describe their minimally invasive technique for performing a superficial temporal artery (STA) to middle cerebral artery (MCA) bypass, which relies on an enlarged bur hole (2-2.5 cm) rather than the standard craniotomy. They perform this procedure in a minimally invasive fashion, using CT angiography for intraoperative neuronavigation as well as for preoperative identification of the donor and recipient vessels and planning of bur hole location. They present 2 cases in which this procedure was used, including one involving a patient with multivessel occlusive disease and significant cerebrovascular hemodynamic compromise in whom they performed the procedure using only local anesthetic and propofol sedation in order to minimize the risk of hypotension associated with the use of general anesthetic agents. A comprehensive literature search revealed no previously published case of an extracranial-intracranial arterial bypass procedure performed in an awake patient. The authors have adopted the described minimally invasive method for all STA-MCA bypass procedures. The awake setting, however, is reserved for specific indications, primarily patients with severe moyamoya disease, in whom ventilator-related hypocarbia can result in intraoperative ischemia, or patients with multivessel occlusive disease and significant cerebral hemodynamic compromise, in whom general anesthesia-related hypotension can lead to intraoperative ischemia.
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PMID:Minimally invasive superficial temporal artery to middle cerebral artery bypass through an enlarged bur hole: the use of computed tomography angiography neuronavigation in surgical planning. 1875 90

The objective of this study was to determine the outcome of femoral vein (FV) access as either a FV thigh transposition or upper extremity FV translocation. This is a retrospective review of all end-stage renal disease (ESRD) patients who underwent FV access at the University of Colorado Health Sciences Center from December 2004 to May 2007. Demographics, number of prior access procedures, FV dialysis access procedure, periprocedural complications, mean follow-up, secondary access-related procedures, and access function were recorded. Complications were subdivided into FV harvest site- and ischemia-related. Nineteen patients underwent FV access during the study period: 10 underwent FV thigh transpositions and nine underwent upper extremity FV translocations. The median number of prior access procedures was two. The median hospital stay was 3 days, and there were no perioperative deaths. Eight patients had FV harvest site complications: six lymphoceles, one AVF infection requiring ligation, and one compartment syndrome requiring fasciotomy. Three (16%) patients had ischemic complications: one required ligation of the AVF and two required distal revascularization interval ligation. Seventy-nine percent of patients had a functioning access at a mean follow-up of 6 months (range 23 days to 3 years). Four FV arteriovenous accesses required one or more endovascular procedures to maintain function at 12 months. The use of FV access in ESRD is durable at intermediate follow-up but has significant morbidity. FV access should be reserved for good-risk patients who have exhausted other autogenous options.
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PMID:Arteriovenous fistula construction using femoral vein in the thigh and upper extremity: single-center experience. 1880 77

Stroke is a leading cause of death and the primary cause of serious, long-term disability in the United States. Joint guidelines from the American Heart Association (AHA) and American Stroke Association (ASA), as well as recent guidelines from the Eighth American College of Chest Physicians (ACCP) Conference on Antithrombotic and Antiplatelet Therapy, recommend aspirin, clopidogrel, or extended-release dipyridamole plus aspirin as acceptable first-line options for secondary prevention of ischemic events in patients with a history of ischemic stroke or transient ischemic attack (TIA). The ACCP strongly recommends the combination of extended-release dipyridamole plus aspirin over aspirin monotherapy (highest level of evidence) and suggests clopidogrel monotherapy over aspirin monotherapy (lower level of evidence). The AHA-ASA guidelines suggest that either extended-release dipyridamole plus aspirin or clopidogrel monotherapy should be used over aspirin monotherapy. Both guidelines recommend avoiding the combination of clopidogrel and aspirin for most patients with previous stroke or TIA. Results from recent trials evaluating combination antiplatelet therapy have been published that enhance the AHA-ASA recommendations and provide the foundation for the updated ACCP guideline. To identify pertinent combination antiplatelet trials, a MEDLINE search of the literature from 1967-2007 was performed. Two trials were identified--the European-Australasian Stroke Prevention in Reversible Ischemia Trial (ESPRIT) and Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA). The ESPRIT compared aspirin monotherapy with the combination of aspirin plus extended-release dipyridamole for prevention of secondary ischemic events in patients with a history of TIA or minor stroke. The CHARISMA trial compared aspirin plus clopidogrel with aspirin alone in a population at high risk for atherothrombotic events using the composite outcome of myocardial infarction, stroke, and death from cardiovascular causes. Data from ESPRIT add to evidence that the combination of aspirin plus extended-release dipyridamole is superior to aspirin alone. The findings of the CHARISMA trial reinforce recommendations from both AHA-ASA and ACCP that the combination of aspirin and clopidogrel be reserved for special populations requiring this antiplatelet combination (e.g., those who have had coronary artery stenting).
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PMID:Combination antiplatelet agents for secondary prevention of ischemic stroke. 1882 19


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