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A 73-year-old woman with a history of hypertension and hyperlipidemia presented with a sharp pain ranging from the right shoulder to the upper limb. She had suffered a sharp pain at rest accompanied by general fatigue and nausea for about ten months prior to admission. Her white blood cell count was 12,800/microl, and her serum C-reactive protein was 17.5 mg/dl. A chest computed tomography scan revealed an aneurysmal change of the origin of the brachiocephalic artery. Pseudoaneurysm due to infection and aortic dissection was considered as a preoperative diagnosis. A total arch replacement was performed under cardiopulmonary bypass, deep hypothermia, and selective cerebral perfusion. Postoperatively, a bacteriologic culture of the contents of the aneurysm revealed Staphylococcus aureus. Perioperative administration of antibiotics was effective and the postoperative course was uneventful.
Jpn J Thorac Cardiovasc Surg 2004 Mar
PMID:Mycotic pseudoaneurysm of the brachiocephalic artery. 1507 52

Pancreaticoduodenal artery aneurysms (PDAA) are very rare (2% of the visceral aneurysms) but characterized by a high mortality rate if ruptured. Here a case of ruptured PDAA with an atypical clinical presentation that simulated an acute hepatobiliar syndrome is reported. A 60-year-old female presented with epigastric pain, nausea, gastric vomiting, elevated levels of hepatic enzymes, normal hemoglobin and cholelithiasis on echography. With persistent pain and progressively decreasing hemoglobin, an urgent contrast computed tomography was performed and revealed a large retroperitoneal hematoma that appeared to come from a branch of the superior mesenteric artery (SMA). A selective SMA-angiography showed a small aneurysm of the antero-superior pancreaticoduodenal artery with signs of hemorrhage. The patient underwent surgical ligature of the PDAA, after superselective transcatheter arterial embolization appeared technically impossible. The postoperative period was characterized by a progressive normalization of the hepatic values and hemoglobin and a post-operative angiogram confirmed the total exclusion of the PDAA and the integrity of the posterior pancreaticoduodenal arch. The pre-operative diagnosis of PDAA is usually very difficult. Symptoms can be vague or misleading, as in our case. Angiography is the most accurate diagnostic tool to locate a ruptured PDAA. Moreover, it can be immediately used for urgent endovascular treatment. Post-operative angiography is essential to confirm the total exclusion of the PDAA and demonstrate visceral circulation.
J Cardiovasc Surg (Torino) 2004 Apr
PMID:Ruptured pancreaticoduodenal artery aneurysm. A case report and review of the literature. 1517 52

Arteriographic examination of the coronary, cerebral, and peripheral circulatory systems is the ultimate diagnostic technique for the identification and quantification of atherosclerotic occlusive disease. In the past, hospitalization has been required for this invasive procedure. Recently, however, the concept of outpatient catheterization and arteriography has become a reality. To investigate the integrity, safety, and cost-effectiveness of our outpatient invasive procedures laboratory, we analyzed our experience with 254 cardiac catheterizations and 174 peripheral arteriograms performed during a 20-month period. There were no deaths or major complications. Minor complications (11%) included bleeding from the cutdown site, nausea, numbness, and allergic reactions. Two patients with arrhythmias required cardioversion. Nine patients (2%) were transferred to the hospital for observation or immediate surgery due to the nature of their atherosclerotic lesions. This study reveals (1) the technical quality, safety, indications, and contraindications for outpatient catheterization and arteriography; (2) the enthusiastic patient acceptance of outpatient invasive diagnostic studies; (3) the economic impact of these procedures on escalating health-care costs; and (4) the potential for outpatient catheterization and arteriography on a broad scale.
Cardiovasc Dis 1981 Jun
PMID:Outpatient cardiac catheterization and arteriography: Twenty-month experience at the Arizona Heart Institute. 1521 7

A number of newer antianginal agents, including nicorandil, trimetazidine, and ivabradine, have been synthesized in recent years, but ranolazine, a piperazine derivative that partially inhibits fatty acid oxidation and the late INa current in animal models, is of particular interest mechanistically. Earlier clinical trials with immediate-release ranolazine led to the current sustained-release version tested in the Monotherapy Assessment of Ranolazine In Stable Angina (MARISA) (n = 193) and Combination Assessment of Ranolazine In Stable Angina (CARISA) trials (n = 823) of patients with chronic angina and severe limitation of exercise capacity (ie, < 5 metabolic equivalents). MARISA was a placebo-controlled, randomized trial that compared ranolazine monotherapy (500 mg, 1000 mg, and 1500 mg, twice daily) to placebo. CARISA was a placebo-controlled trial that randomized patients on background beta-blocker or calcium antagonist therapy to placebo or ranolazine (750 mg or 1000 mg, twice daily). Both studies showed a significant increase in total exercise duration, time to angina onset, and time to 1 mm ST segment depression. The average magnitude of increase in exercise duration over placebo was 29 to 56 seconds at peak and 24 to 46 seconds at trough with the 3 doses tested in MARISA, and 24 to 34 seconds greater than placebo with the 2 doses used in CARISA. The beneficial effect was achieved without clinically important changes in rest or exercise heart rate or blood pressure. Weekly angina attack frequency and nitroglycerin usage were significantly reduced in a dose-dependent manner in the 12-week CARISA trial. Reported adverse effects were similar in MARISA and CARISA and consisted of asthenia, nausea, constipation, and dizziness. Syncope, reported in 8 patients at doses of 1000 mg twice daily or more may be related to attenuation of alpha-1 receptor activity. The mean QTc interval increased with dose and was less than 10 msec on ranolazine at 1000 mg twice daily. The mortality rates at 1 and 2 years in MARISA and CARISA open-label run-on studies were 2% and less than 5%, acceptable for this high-risk population with limited exercise capacity. In conclusion, clinical trial evidence with ranolazine to date is consistent with its proposed mechanism of action and demonstrates an effective antianginal profile that may benefit patients with severe chronic angina.
J Cardiovasc Pharmacol Ther 2004 Sep
PMID:Efficacy and safety of a metabolic modulator drug in chronic stable angina: review of evidence from clinical trials. 1537 31

A 67-year-old man with neurally mediated syncope (NMS) complicated by prostatic hypertrophy responded well to combined therapy with pirmenol and midodrine. In 2003, syncope occurred while the patient was driving a car. Results of head-up tilt-table testing (HUT) suggested a mixed type of NMS. Oral administration of disopyramide provided severe urinary obstruction. Pirmenol treatment was not associated with syncope during ordinary HUT, but nausea, sweating, and syncope occurred during HUT with provocative administration of isosorbide dinitrate. Combined therapy with pirmenol and midodrine avoided syncope during HUT, and has prevented attacks since discharge from the hospital.
Cardiovasc Drugs Ther 2004 Sep
PMID:A patient responding to combined therapy with pirmenol and midodrine for refractory neurally mediated syncope complicated by prostatic hypertrophy. 1571 44

The specific changes of same-day admission, choice of bypass conduit, use of cardiopulmonary bypass and rapid recovery have been highlighted to reflect current changes in cardiac surgical care. Practice guidelines with respect to symptom management of postoperative pain, nausea and atrial fibrillation are future topics to be discussed reflecting additional practice changes in cardiac surgery.
Can J Cardiovasc Nurs 2005
PMID:Changes in cardiac surgery. 1578 93

Sitaxsentan is an orally active, selective endothelin-A receptor antagonist that may benefit patients with pulmonary arterial hypertension by blocking the vasoconstrictive effects of endothelin-A receptors, while maintaining the vasodilator and endothelin-1 clearance functions of the endothelin-B receptors. In its first randomized, placebo-controlled study, sitaxsentan improved exercise capacity assessed by the 6-min walk test, New York Heart Association functional class, cardiac index and pulmonary vascular resistance in New York Heart Association Class II, III and IV patients with idiopathic pulmonary arterial hypertension and pulmonary arterial hypertension related to connective tissue disease or congenital heart disease. Although doses of 100 and 300 mg once daily demonstrated equivalent efficacy, the lower dose had a better safety profile. Additional studies are ongoing to assess the relative safety and efficacy of 50 and 100 mg once-daily dosing. The most common side effects include rhinitis, headache, peripheral edema, chest pain, nausea, constipation, increased prothrombin time/international normalized ratio (in patients on warfarin), flushing and insomnia. As with other endothelin receptor antagonists, increases in hepatic transaminases have been observed with sitaxsentan. Initial studies using the selective oral endothelin-A receptor antagonist sitaxsentan in pulmonary arterial hypertension patients have revealed a favorable risk-benefit therapeutic profile with the 100 mg once-daily dose.
Expert Rev Cardiovasc Ther 2005 Nov
PMID:Sitaxsentan: a novel endothelin-A receptor antagonist for pulmonary arterial hypertension. 1629 89

A multicenter, double-blind study was performed to compare the antianginal efficacy and safety of the new dihydropyridine calcium antagonist amlodipine with the benzothiazepine calcium antagonist diltiazem in patients with stable exertional angina pectoris. Following a 2-week placebo run-in period, 39 patients were randomized to receive amlodipine (2.5-10 mg once daily) and 41 patients to receive diltiazem (60-120 mg three times daily) in an 8-week double-blind treatment phase. The study used standardized bicycle exercise testing as a primary efficacy assessment. Patients also recorded angina frequency and nitroglycerin (NTG) tablet consumption/ week. Treatment with amlodipine and diltiazem resulted in an improvement in total exercise time, time to angina and total work, mean ST-segment deviation at maximum common load, median number of angina attacks/week, and NTG tablet consumption/week. The incidence and severity of possibly treatment-related side effects and laboratory test abnormalities were comparable for both drugs. The most frequently reported side effects were dizziness, headache, peripheral edema, and nausea. Two patients withdrew from diltiazem treatment due to pruritus in one case and severe headache and moderate dyspnea in the other. No amlodipine-treated patients withdrew due to side effects. In conclusion, this study demonstrated that the antianginal efficacy and tolerability of amlodipine is equivalent to diltiazem, but amlodipine has the advantage of once-daily dosing.
J Cardiovasc Pharmacol 1991
PMID:An 8-week double-blind study of amlodipine and diltiazem in patients with stable exertional angina pectoris. 1629 11

The purpose of this study was to compare symptom presentation and illness behavior among women and men with acute myocardial infarction and assess various aspects that influence prehospital delay. This is a cross-sectional, retrospective study using self-reported questionnaires. The sample consisted of 82 women and men in Norway, up to 65 years of age, with first-time acute myocardial infarction between March and October 1999. The findings demonstrated that the most commonly reported symptom in both genders was chest pain. More than 90% of women and men experienced chest pain, with no difference between the genders. More women than men had nausea as well as pain located in their arms, back, jaw, and throat. More men than women attributed their symptoms to be cardiac in origin. Experiencing pain in the shoulders, attributing symptoms to be noncardiac, consulting a family member, and contacting several medical practitioners increased prehospital delay. During the year before the event, women were more likely to experience fatigue than men. The conclusion of this study is that women experienced a greater diversity of symptoms than men. Acute symptoms, interpretation of symptoms, and illness behavior may influence prehospital delay.
Prog Cardiovasc Nurs 2006
PMID:Are there gender differences related to symptoms of acute myocardial infarction? A Norwegian perspective. 1652 64

A secondary analysis was conducted from data gathered from 239 patients with acute myocardial infarction presenting to the emergency departments of three hospitals to explore the influence of age on delay time, experienced symptoms, and factors predicting a delay of >1 hour. During hospitalization, a structured interview about the patients' experience before hospital admission was completed and their medical records were reviewed. The median delay before seeking treatment was not significantly different between older (2.5 hours) and younger patients (2.1 hours). Older patients were significantly less likely to report classic pain in the center of the chest and other associated symptoms such as sweating and nausea; they also used fewer words to describe their discomfort compared with younger patients. Independent predictors of longer delay were: contacted physician, lacked similarity between experienced and expected symptoms, did not use 911 (older adults), lived alone, and contacted physician (younger adults). Primary care providers need to be aware that elderly persons are more likely to have mild or ambiguous acute myocardial infarction symptoms and education is needed for elderly persons regarding not only acute myocardial infarction symptoms but also rapid, action-centered decisions to attribute symptoms to heart problems and initiate ambulance use.
Prog Cardiovasc Nurs 2006
PMID:The influence of age on acute myocardial infarction symptoms and patient delay in seeking treatment. 1652 65


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