Critical care clinics
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Patients with decompensated heart failure should be managed in an aggressive and proactive manner, using predominantly hemodynamic and end-organ function goals. This management is in contrast to the chronic maintenance therapy of patients with heart failure, where a neuroendocrine approach is indicated. Underlying anatomic targets for intervention should be sought aggressively and addressed. Patients who prove resistant to standard measures should be considered for early referral to heart transplant centers for more definitive measures, including evaluation for heart transplantation and mechanical circulatory support if necessary.
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The contemporary management of acute myocardial infarction continues to evolve rapidly. The ultimate goal of therapy is timely, complete, and sustained myocardial reperfusion. There is a powerful time-dependent effect on mortality, and thus the balance between the time and likelihood of maximal reperfusion is crucial in deciding whether to use primary percutaneous balloon angioplasty or thrombolysis as the initial reperfusion strategy. ⋯ Combination therapy with low-dose fibrinolytics, glycoprotein IIb/IIIa inhibitors, and low molecular weight heparin, with or without subsequent early planned percutaneous coronary interventions, may provide the optimal strategy for maximal coronary reperfusion, but the results of large, randomized mortality trials currently underway need to be analyzed. Risk stratification will continue to play a major role in determining which patients should receive a specific therapy. The care of the patient with an acute myocardial infarction will continue to be a challenge requiring the proper selection from the vast pharmaceutic and interventional options available.
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Acute myocardial infarction continues to be the major determinant of death and disability in Western countries. Despite large improvements in management during the last 20 years, its high morbidity and mortality rates provide a stimulus to search intensively for different and widely applicable therapeutic options.
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Significant advances have been made in the management of cardiac arrhythmias. New technology has enhanced the ability to understand and treat a variety of tachycardias. ⋯ A new indication for cardiac pacing is evolving as a supplemental treatment for patients with refractory congestive heart failure. These and other advances provide numerous exciting options for management of cardiac patients.
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Echocardiography has become an invaluable tool in the management of critically ill patients. Its safety and portability allow for use at the bedside to provide rapid, detailed information regarding the cardiovascular system. ⋯ Recently, the power of clinical echocardiography has been augmented by the use of Doppler techniques to evaluate cardiovascular hemodynamics. An in-depth understanding of the proper use of echocardiography is a prerequisite for the intensivist.