Cardiology
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Fluid overload may occur in patients with congestive heart failure, especially when there is associated acute renal failure. When the pharmacological approach is not sufficient to maintain the patient's fluid balance, extracorporeal therapies must be instituted. However, since the ultrafiltration rate may be faster than fluid refilling from the interstitial space, remarkable changes in the circulating blood volume may occur. ⋯ The variations in blood pressure were paralleled by variations in blood volume, which were greater with UF than with SCUF. In conclusion, extracorporeal ultrafiltration can be used to control the fluid balance in congestive heart failure, but it is advisable to prescribe low ultrafiltration rates over an extended period of time. The use of on-line blood volume monitors can be of further help in improving tolerance and the hemodynamic response.
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In patients with left bundle branch block (LBBB) and acute chest pain, the association between the clinical presentation and the diagnosis of myocardial infarction has not been investigated. We sought to identify features in the clinical history of patients with LBBB and acute cardiopulmonary symptoms that predict myocardial infarction among candidates for reperfusion therapy. ⋯ Coronary heart disease risk factors, past cardiac history, prior LBBB on the ECG, and presenting symptoms did not predict whether patients were having myocardial infarction. The clinical history was not effective at distinguishing LBBB patients with myocardial infarction among patients who appeared to be candidates for acute reperfusion therapy.
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Sudden death following blunt chest trauma is a frightening occurrence known as 'commotio cordis' or 'concussion of the heart'. It is speculated that commotio cordis could be caused by ventricular fibrillation secondary to an impact-induced energy that was transmitted via the chest wall to the myocardium during its vulnerable repolarization period. ⋯ Serial electrocardiographic changes (bifascicular conduction block and T wave inversion in precordial leads) were noticed in this patient. Our case suggested that coronary vasospasm might also play a role in commotio cordis.
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Thrombin generation (TG) is an important pathogenic factor in acute coronary syndromes including acute myocardial infarction (AMI). Since the diagnostic utility of TG remains uncertain we sought to determine whether markers of TG may triage patients presenting to the Emergency Department with chest pain. Soluble plasma levels of prothrombin fragment 1+2 (F(1+2)), and thrombin/antithrombin III complexes (TAT) were determined by ELISA in 80 patients presenting with chest pain to the Emergency Department and compared with 20 controls. ⋯ Moreover, plasma F(1+2) levels were significantly lower than in healthy controls (0.84 +/- 0.10 ng/ml versus 1.22 +/- 0.11, p = 0.026). At the time of presentation to the Emergency Department, F(1+2) and TAT failed to suitably triage patients with chest pain. The surprisingly low levels of TG markers in AMI patients before applying intensive therapy and reperfusion strategies deserves further investigation.
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Randomized Controlled Trial Clinical Trial
Effect of isosorbide-5-mononitrate on exercise performance and clinical status in patients with congestive heart failure. Results of the Nitrates in Congestive Heart Failure (NICE) Study.
Nitrate therapy improves hemodynamics in patients with heart failure, but the chronic effects of oral nitrates on exercise performance and clinical status have not been well studied. ⋯ ISMN added to captopril increased treadmill exercise time in patients with heart failure and a lesser reduction in baseline ejection fraction, although for the group as a whole, the increase in treadmill time was not significant.