Gene/Protein Disease Symptom Drug Enzyme Compound
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Query: UMLS:C0151744 (myocardial ischemia)
 31,282 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

With the aid of a protracted passive postural test, the rate of occurrence and the variants of orthostatic hypotensive reactions in hypertensive patients were studied. Three hundred and eighty-two consecutive tilt tests in 161 hypertensive patients, 89.4% of whom were taking antihypertensive medications, were reviewed. Orthostatic hypotensive reactions were recognized in 33.8% of examinations. Thirty-one hypotensive episodes (8.1%) were associated with symptoms of cerebral ischemia, resulting in termination of the tilt test at a median of 5 min from onset (range 1-30 min). A survey of possible risk markers of symptomatic hypotensive reactions during tilt showed that increasing age was associated with significantly increased risk (P < 0.001), while gender, office blood pressure (BP), diabetes mellitus, ischemic heart disease, anxiety, history of syncope, and treatment with antihypertensive drugs were not. Asymptomatic orthostatic hypotension early in the course of the tilt test was a weak predictor of symptomatic hypotensive reactions later during the test (positive predictive value 17.4-33.3%). Among the 31 symptomatic hypotensive reactions, 10 were typical cases of orthostatic hypotension, four were typical vasovagal reactions, and 17 episodes were difficult to classify. The implications of symptomatic hypotensive reactions triggered by protracted head-up tilt in hypertensive patients are unknown and can only be elucidated in longitudinal studies.
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PMID:Hypotensive reactions on passive head-up tilt testing of hypertensive patients. 887 99

Application and feasibility of automated ambulatory blood pressure measurement (ABPM) in the elderly are comparable to younger age groups. Major side-effects are sleep disturbances and pain during cuff-inflation. The main indications for ABPM are diagnosis and control of treatment in hypertensive patients. Further indications are the diagnosis of syncope or hypotensive disorders and the diagnostic work-up of symptoms like vertigo, dizziness and dyspnea. In hypertensives, ABPM can easily assess the "white coat" effect and cases of "white coat" hypertension (prevalence in the elderly 15-25%). The prognostic implications of "white coat" hypertensions remain to be determined. Recording of the total 24-h blood pressure profile with analysis of circadian blood pressure changes, the day-night difference and the early morning surge raises the possibility to assess age-specific patterns. The drop in blood pressure at night (during sleep) is usually decreased and less frequently observed in elderly hypertensives. Possible explanations include decreased daytime activity, an altered sleep pattern in the elderly and secondary forms of hypertension. So-called "non-dippers", with no adequate drop in night-time blood pressure, show a significant increase in cardiovascular complications. Control of treatment via ABPM can assess non-responders and cases of overtreatment, and permits a fairly objective analysis of side-effects. Episodes of transient myocardial ischemia and possible trigger mechanisms can be assessed by simultaneous application of ABPM and Holter monitoring. The insufficient control of hypertension in the majority of elderly patients and the current lower target blood pressures in the elderly call for new methods to improve the level and quality of antihypertensive treatment. Although ABPM provides a closer correlation to target organ damage than measurement of office (casual) blood pressure, and ABPM frequently improves or at least facilitates the care of elderly hypertensive patients, it remains to be determined whether ABPM can finally improve the long-term outcome of these patients.
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PMID:Automated blood pressure measurement (ABPM) in the elderly. 889 6

To minimize drug problems in the treatment of supraventricular tachycardias, it is important to understand the spectrum of adverse events and to identify patients at high risk for these problems. Adverse cardiac and non-cardiac effects are associated, to varying degrees, with currently available antiarrhythmics. Cardiac adverse events include the development of rhythm disturbances, such as ventricular tachycardia or torsades des pointes, may result in syncope or death. In a meta-analysis of six randomized trials of quinidine vs placebo for atrial fibrillation, 1.8% of quinidine-treated patients died as opposed to 0.3% of placebo-treated patients. This increase in mortality was also noted in patients enrolled in the Stroke Prevention in Atrial Fibrillation Trial who were treated with type I antiarrhythmics. This increase in mortality was confined primarily to patients with a history of congestive heart failure. In a randomized trial of propafenone and sotalol for the treatment of atrial fibrillation, two out of 50 patients receiving sotalol died suddenly, one of whom had hypokalaemia-associated torsades des pointes. No patient receiving propafenone died during this trial. In a meta-analysis of propafenone's effect in treating supraventricular tachyarrhythmias in over 3100 adult patients, overall mortality was extremely low at 0.3%. Structural heart disease may increase the risk of antiarrhythmic agents. During inpatient drug trials in patients treated for atrial fibrillation at Brigham and Women's Hospital, adverse cardiac events, primarily bradyarrhythmias, occurred in up to 15% of the patients. Older age and prior myocardial infarction were associated with an increased risk of adverse events. Adverse drug problems may be minimized by careful attention to electrolytes, medications, concomitant medical illnesses, and underlying conduction disease. Careful monitoring of patients during initiation of therapy, especially those patients with ischaemic heart disease, congestive heart failure, and who are older, may minimize drug-related problems.
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PMID:Avoiding drug problems. The safety of drugs for supraventricular tachycardia. 915 74

To assess the clinical characteristics and management of patients with atrial fibrillation (AF), we performed a prospective survey of all acute medical admissions over six months to our hospital. Of 7,451 such admissions, 245 had AF (110 male, 135 female; mean age 74.4 years). Of these, 213 were Caucasian, 10 black/Afro-Caribbean and 22 Asian. Complete data were available for 185 patients. Of these, 82 had newly diagnosed AF, 83 had previous chronic AF and 20 had paroxysmal AF. The main presenting features was dyspnoea, stroke and syncope. A history of ischaemic heart disease was present in 64, heart failure in 46, hypertension in 51 and rheumatic heart disease in 13, while 31 had a previous stroke. Chest X-ray showed cardiomegaly and pulmonary oedema in 121 patients, but was normal in 28. Echocardiography showed poor cardiac function in eight patients and enlarged left atria in five. Only 28% of those with previously diagnosed AF were on anticoagulation. Of the newly diagnosed patients, only 18% were started on anticoagulants. Cardioversion was attempted or planned in only 6%. The primary diagnosis on discharge was heart failure in 45, stroke in 24 and myocardial infarction in 12. AF remains a common arrhythmia among acute medical admissions and is commonly associated with heart failure and a high mortality. There is still a reluctance to start anticoagulant therapy or to perform cardioversion in such patients.
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PMID:Acute admissions with atrial fibrillation in a British multiracial hospital population. 915 52

The noninvasive assessment of patients who present with syncope is based on a thorough, complete history and physical examination. The history requires close attention to precipitating events and the description of the spell. Often, patients are poor historians with regard to symptoms leading up to and following the episode of syncope. Therefore, it is important to interview individuals who observed the spell to improve the accuracy of the history and sort out whether or not the spell was due to cardiogenic syncope, vasodepressor syncope, or a neurologic disorder. Carotid sinus massage is a useful procedure that can be performed during the routine physical examination, identifying patients who are at increased risk for carotid sinus syncope because of hypersensitivity of the carotid sinus. The clinician must be careful to attribute the clinical syncope to carotid sinus hypersensitivity only when the spell induced at the time of carotid massage reproduces the clinical spell. Routine laboratory tests are commonly performed, although the blood tests rarely yield information to confirm the cause of syncope. The routine ECG is often helpful identifying abnormalities of rhythm, conduction, or morphology that give a clue as to the cause for the patient's syncope. The most helpful aspect of ECG recording is to obtain a recording during an episode of syncope when exact correlation can be made between the ECG findings and the patient's symptoms. Recording the ECG during the spell can be achieved using 24-hour ambulatory monitoring, an event recorder, or a memory loop recorder. Twenty-four-hour ambulatory monitoring is useful in patients who have frequent spells that would be expected to be recorded during 1 or 2 days of monitoring. These individuals need to have a non-life-threatening spell and therefore be safe to evaluate as an outpatient. The event recorder and loop memory recorder have proved extremely helpful in evaluating spells that occur too infrequently to be recorded by 24-hour or 48-hour ambulatory monitoring. The nature of these recording devices does require that the patient or a companion be able to activate the monitor at the time of symptoms. If a patient experiences syncope but is unable to activate the device, the important information as to what the rhythm was doing at the time of symptoms is lost. The implantable loop recorder should prove to be uniquely advantageous by allowing extended ECG recording with the device activated by the patient or companion recording 20 minutes before and 4 minutes after device activation. Signal-averaged electrocardiography is most helpful in assessing patients with ischemic heart disease with a substrate capable of supporting a reentrant ventricular arrhythmia. This test should be used in combination with other historical or laboratory predictors of arrhythmic events such as history of myocardial infarction or abnormal ventricular function assessed by echocardiography. In this setting, the signal-averaged ECG helps to identify patients at increased risk for ventricular tachycardia as the cause of syncope who thus may benefit from electrophysiologic testing.
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PMID:Value and limitations of noninvasive assessment of syncope. 916 10

Mortality in the total occlusion of the left main coronary artery is very high, and the few cases who lived reported were very ill and symptomatic patients. We present a case with angiographic documentation of total occlusion of the left main coronary artery in a patient without angina and with a normal rest electrocardiogram in which a syncope was the only symptom. Severe isolated silent ischemia was induced during an exercise test. Total occlusion of the left main coronary artery associated to silent myocardial ischemia without cardiac failure has never been previously reported.
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PMID:[Occlusion of the left main coronary artery with silent ischemia and syncope]. 928 Oct 18

Spontaneous coronary artery dissection is a rare cause of acute myocardial ischemia or death that is generally not detected until an autopsy is performed. It occurs in relatively young people and particularly in females. To date, its prognosis and treatment are not well defined. We describe our experience with one patient with acute myocardial infarction due to spontaneous dissection of the right coronary artery, which was treated successfully through direct coronary angioplasty. A 48-year-old man, heavy smoker, was admitted to our CCU for an acute inferior myocardial infarction with right ventricle involvement, which was complicated by the onset of cardiogenic shock (severe arterial hypotension, cold, pale and clammy skin, decrease in mental alertness, marked bradycardia due to a complete atrioventricular block). Since systemic thrombolysis was contraindicated (syncope followed by cranial trauma at the onset of symptoms), the patient underwent urgent coronary angiography that showed a proximal right coronary subocclusion with a filling defect and oblique linear density indicating possible dissection. Primary angioplasty was successfully attempted and a good distal flow was achieved (TIMI 3), but coronary artery dissection became more evident, with a double lumen extending over the distal segment just to the crux. Coronary stenting was not performed because optimum anticoagulant therapy was contra-indicated due to cranial trauma. Standard medical therapy was started after the procedure and coronary angiography, which was repeated before the patient was released from hospital, showed complete healing of the right coronary artery without any signs of dissection. The patient remained asymptomatic at a six-month follow-up check, with a negative exercise test. In our opinion, coronary angioplasty is a suitable therapeutic option in the treatment of spontaneous coronary dissection. More extensive experience is needed in order to standardize the most suitable therapeutic procedure in this rare cause of myocardial ischemia.
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PMID:[Spontaneous coronary dissection as a cause of acute myocardial infarct: description of a case and review of the literature]. 931 10

Nitrates, which have been used for more than a century, are the second oldest drug (after digitalis alkaloids) in the cardiological pharmacological arsenal. However, several facets of their mode of use still remain controversial. Their vasodilator and arteriolodilator action (especially in coronary vessels) and their platelet aggregation inhibitory effect make them useful drugs, particularly in all clinical forms of ischaemic heart disease (unstable or stable angina and acute myocardial infarction), for the prevention or treatment of ischaemic episodes (silent or not) and also in heart failure where nitrates are useful not only as symptomatic treatment (alone or associated with diuretics), but also in view of their positive effect on survival (associated with hydralazine: V-Heft I trial). At the present time, nitrates can be administered via the sublingual, oral, intravenous of transdermal routes in the form of nitroglycerin and isosorbide dinitrate or mononitrate (short-acting and sustained-effect forms). Their rare contraindications concern patients suffering from severe hypotension (< 70 mmHg), severe anaemia, glaucoma or intracranial hypertension. The most serious adverse effects are pulsatile headache (which usually disappear after several days), postural hypotension (possibly causing fainting), facial erythema, vertigo, palpitations or nausea and vomiting. Most of these adverse effects can be controlled by dosage adaptation and it is rarely necessary to stop treatment. However, the major problem raised by the use of nitrates concerns the development of a tolerance. The pathophysiology of this multifactorial phenomenon is still unclear. The protagonist role played by loss of SH groups or activation of humoral feedback mechanisms, with an increase of circulating catecholamine levels, activation of the R-A-A system and increased plasma volume, has been postulated. This complication can be avoided by prescribing intermittent treatment, with a drug-free interval of 10-12 hours per day. A single dose of a sustained-release preparation (60 mg of isosorbide dinitrate or 40 to 60 mg of isosorbide mononitrate), or 2 or 3 doses of a short-acting preparation (20-40 mg of isosorbide mononitrate) can be prescribed via the oral route. When the transdermal route is used, the patch should be left in place for 12 hours. Treatment should be started at low doses, which are then gradually increased. The free period is usually at night, which can be covered, when necessary, by other antiischaemic drugs (for example, beta-blockers and/or calcium channel blockers), already usually used in combination with nitrates. This interruption is not accompanied by a rebound phenomenon. It must be remembered that nitrates potentiate the action of other vasodilators and calcium channel blockers and that, in some patients, intravenous nitroglycerin reduces the anticoagulant effect of heparin, while indomethacin can inhibit their vasodilator effect. Nitrates are therefore in very good health despite their advanced age and, when used correctly, they continue to be very useful in the pharmacological treatment of cardiovascular diseases.
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PMID:[Principles and rules of the use of nitrates]. 945 73

A 71-year-old man who had ischemic heart disease with poor left ventricular function and ventricular tachycardia was admitted to hospital for evaluation. Cardiac catheterization was performed on August 19, 1996, and right coronary arteriography revealed total occlusion at segment 3. Left coronary arteriography revealed total occlusion at segment 6, and a lesion at segment 13 was 75% occluded. Partial collateral flow from the right ventricular branch to the left anterior descending artery was demonstrated, and the left ventricular ejection fraction was 24%. Recurrent ventricular tachycardia followed by pre-syncope occurred from August 23, 1996, and the patient underwent emergency coronary artery bypass surgery to the left anterior descending artery and circumflex artery using saphenous vein grafts. Ventricular tachycardia followed by pre-syncope occurred frequently after the bypass surgery, and antiarrhythmic agents (Vaughan Williams classification Ia and Ib groups) were ineffective. He received amiodarone (100 mg/day after a loading dose of 200 mg/day for 2 weeks) from September 6, 1996. His symptoms of arrhythmia decreased, and side effects have not been observed. Low-dose amiodarone was effective in this case of ischemic heart disease with left ventricular dysfunction and sustained ventricular tachycardia.
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PMID:[Effective low-dose amiodarone therapy for ventricular tachycardia complicated with ischemic heart disease and poor left ventricular function in an elderly patient]. 949 69

Coronary aneurysm in Kawasaki's disease (Acute febril infantile mucocutaneous lymph node syndrome, MCLS) may cause sudden death in childhood and ischemic heart disease in adults. We encountered two adult autopsy cases of Kawasaki's disease with multiple coronary aneurysms. The first case was a 56-year-old man who hospitalized due to recurrent syncope since 51 years of age. At age 55 coronary angiography (CAG) had shown multiple aneurysms in the left and right coronary artery. In September 1991, he developed chest pain and was brought to the hospital, almost dead on arrival (DOA). The patient died later the same day despite cardiopulmonary resuscitation. Autopsy findings showed cardiomegaly (470 g) with multiple coronary aneurysms of three coronary arteries. Microscopically, intimal thickening and medial thinning were found in the aneurysmal wall with calcification and disruption of the internal elastic lamina. The second case, a 28-year-old man had been diagnosed with rheumatic fever and mitral regurgitation at 4 years of age. Coronary aneurysms were noted on CAG at 26 years of age. In April 1992, he developed fever and was admitted to a local hospital where he was diagnosed with infectious endocarditis. After his being transferred to our hospital, disturbance of consciousness suddenly developed and he died in September 1992. Autopsy findings showed cardiomegaly (430 g) with left ventricular hypertrophy and multiple coronary aneurysms in left anterior descending coronary artery and left circumflex coronary artery. The aneurysmal wall showed intimal thickening and medial thinning with multiple recanalizations of occlusive lumina and fibrous intimal thickening. The mitral valve showed mild fibrosis and calcification without valvular deformity. There was no evidence of bacterial endocarditis. Both cases were finally diagnosed as Kawasaki's disease. Ischemic heart disease or lesions related to coronary aneurysm in Kawasaki's disease may show an increased incidence in the near future. Kawasaki's disease should have been followed even in adulthood after treatment in childhood.
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PMID:[Adult multiple coronary aneurysms of Kawasaki's disease's sequelae; two autopsy cases]. 952 43


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