Rev Cardiovasc Med
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Heart failure (HF) remains a major public health problem, affecting 5 million patients in the United States. The personal burden of HF includes debilitating symptoms, activity limitations, frequent hospitalizations, arrhythmias, and increased mortality. Despite the compelling scientific evidence that angiotensin-converting enzyme inhibitors, beta-blockers, and aldosterone antagonists reduce hospitalizations and mortality in patients with HF, these life-prolonging therapies continue to be underutilized. ⋯ HF disease management programs have also been shown to improve HF treatment, resulting in substantial reduction in hospitalizations and mortality. Application of validated and reproducible noninvasive techniques to monitor patients with chronic HF is an important step in maximizing interventions to improve outcomes in this patient population. Further efforts are clearly needed to improve the monitoring of HF patients in the hospital and outpatient settings, as well as to ensure the implementation of effective strategies and systems that increase the use of evidence-based therapies, in order to reduce the substantial HF morbidity and mortality risk.
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Hyperglycemia is a common complication in hospitalized patients, particularly among patients with acute myocardial infarction. It is an independent predictor of cardiovascular mortality and morbidity. Management of hyperglycemia with intensive insulin therapy has been shown to improve survival, reduce length of stay in intensive care, and decrease complications such as renal failure or prolonged mechanical ventilation in critically ill patients. ⋯ These agents are preferred to controlling blood sugar with sliding scale regimens alone. Oral therapies may also have a role, but many agents may be contraindicated in the acute setting. As hyperglycemia has been shown to have significant adverse impact on patient outcomes in a variety of settings, cardiologists need to play a role in efforts to achieve adequate glycemic control in hospitalized patients with hyperglycemia in an effort to improve patient outcomes.
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The importance of the dissolution and prevention of thrombosis in treating patients with ST-segment elevation myocardial infarction (STEMI) has motivated the development of novel therapies targeting platelet aggregation and thrombus formation. In contemporary practice, the current challenge is the integration of these therapies into reperfusion strategies that may include fibrinolytic therapy or percutaneous coronary revascularization (PCI). Evidence from clinical trials shows that addition of glycoprotein IIb/IIIa inhibition to PCI for treatment of STEMI has substantially lowered the incidence of recurrent ischemic events and improved early survival. ⋯ For example, the recent studies have demonstrated the benefit of clopidogrel treatment among STEMI patients treated with fibrinolysis in reducing the incidence of infarct artery reocclusion and improving early survival. Other anticoagulants under investigation in the management of STEMI include enoxaparin, bivalirudin, and fondaparinux. This review summarizes the current status of pharmacologic and invasive strategies for the treatment of STEMI and describes recent and ongoing directions for clinical investigation.
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Although primary percutaneous coronary intervention has emerged as the preferred reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI), it is available only in a minority of US hospitals. The fundamental problem is that there is presently no organized, uniform, national STEMI triage and treatment system that is comparable to the well-developed, highly successful system in the United States that directs major trauma victims to verified trauma centers. This article reviews prehospital and emergency department triage strategies, systems, and pharmacologic interventions for patients with STEMI that can help shorten the time to reperfusion in these patients.
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A 67-year-old male patient received a coronary artery bypass graft. Less than 2 months afterward, he presented with recurrent exacerbations of congestive heart failure. His response to a standard treatment regimen for heart failure was partly successful, but a few days after discharge he was readmitted for worsening dyspnea and edema. ⋯ Magnetic resonance imaging showed thickened pericardium with exudates in the pericardial space. Cardiac catheterization confirmed the diagnosis, showing equalization of diastolic pressures of the left and right ventricles. The patient underwent subtotal pericardiectomy with resolution of the pericardial disease, but he died from respiratory insufficiency.