American family physician
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American family physician · Mar 2005
ReviewAntiplatelet therapy and anticoagulation in patients with hypertension.
Elevated systemic blood pressure results in high intravascular pressure. The main complications, coronary heart disease, ischemic strokes, and peripheral vascular disease, are related to thrombosis rather than hemorrhage. Some complications related to elevated blood pressure, heart failure, and atrial fibrillation are associated with stroke and thromboembolism. It seems plausible that antithrombotic therapy may be particularly useful in preventing thrombosis-related complications of elevated blood pressure. ⋯ Antiplatelet therapy with ASA cannot be recommended for primary prevention of vascular events in patients with elevated blood pressure, because the magnitude of benefit--a reduction in rates of MI--is negated by a harm of similar magnitude, an increase in rates of major hemorrhage. Antiplatelet therapy is recommended for secondary prevention in patients with elevated blood pressure because the magnitude of the absolute benefit is many times greater. Warfarin therapy alone or in combination with aspirin in patients with elevated blood pressure cannot be recommended because of lack of demonstrated benefit. Glycoprotein IIb/IIIa inhibitors, as well as ticlopidine and clopidogrel, have not been evaluated sufficiently in patients with elevated blood pressure. Further trials of antithrombotic therapy with complete documentation of all benefits and harms are needed in patients with elevated blood pressure.
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Palpitations-sensations of a rapid or irregular heartbeat-are most often caused by cardiac arrhythmias or anxiety. Most patients with arrhythmias do not complain of palpitations. However, any arrhythmia, including sinus tachycardia, atrial fibrillation, premature ventricular contractions, or ventricular tachycardia, can cause palpitations. ⋯ When palpitations occur unpredictably or do not occur daily, an initial two-week course of continuous closed-loop event recording is indicated. Holter monitoring for 24 to 48 hours may be appropriate in patients with daily palpitations. Trans-telephonic event monitors are more effective and cost-effective than Holter monitors for most patients.
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American family physician · Feb 2005
ReviewAntidepressants and antiepileptic drugs for chronic non-cancer pain.
The development of newer classes of antidepressants and second-generation antiepileptic drugs has created unprecedented opportunities for the treatment of chronic pain. These drugs modulate pain transmission by interacting with specific neurotransmitters and ion channels. The actions of antidepressants and antiepileptic drugs differ in neuropathic and non-neuropathic pain, and agents within each medication class have varying degrees of efficacy. ⋯ Tricyclic antidepressants are the most cost-effective agents, but second-generation antiepileptic drugs are associated with fewer safety concerns in elderly patients. Tricyclic antidepressants have documented (although limited) efficacy in the treatment of fibromyalgia and chronic low back pain. Recent evidence suggests that duloxetine and pregabalin have modest efficacy in patients with fibromyalgia.
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American family physician · Feb 2005
ReviewCultural diversity at the end of life: issues and guidelines for family physicians.
Ethnic minorities currently compose approximately one third of the population of the United States. The U. S. model of health care, which values autonomy in medical decision making, is not easily applied to members of some racial or ethnic groups. ⋯ Finally, survey data suggest lower rates of advance directive completion among patients of specific ethnic backgrounds, which may reflect distrust of the U. S. health care system, current health care disparities, cultural perspectives on death and suffering, and family dynamics. By paying attention to the patient's values, spirituality, and relationship dynamics, the family physician can elicit and follow cultural preferences.