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 field of percutaneous coronary intervention continues to progress at a tremendous rate. Advances in techniques, in device technology, and in adjunctive therapy have increased significantly the number of patients who may benefit from angioplasty and have increased the early and long-term success rates of these procedures. Future progress in radiation therapy, IIb/IIIa inhibitors, stent design, and other novel approaches undoubtedly will offer further improvements in the capability of coronary interventions to help patients live longer and feel better.
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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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The pulmonary artery catheter is an invasive hemodynamic monitor that can provide diagnostic information in situations where history and physical examination are inconclusive. Assisting the physician in therapeutic decisions has added to its clinical value. Understanding the information it provides and making thoughtful therapeutic decisions lie at the core of its use. ⋯ Although instituting a moratorium on its use may be extreme, limiting its use to approved indications seems more appropriate. In the future, ready availability of other less invasive methods such as echocardiography may allow clinicians to become less reliant on the PA catheter. Until then, clinicians would be served best by comprehending the intricacies and the limitations of this sophisticated instrument.