Atrial Fibrillation

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ABSTRACT: Age-related changes that affect drug distribution, such as increased total body fat, decreased muscle mass, and decreased total body water, necessitate reduction in the dosage of water- and lipid-soluble agents. Because creatinine clearance declines with age, the dosage of agents that are excreted primarily by the kidney must also be lowered to prevent toxicity. Examples include aminoglycosides, fluoroquinolones, penicillins, procainamide, lithium, angiotensin-converting enzyme inhibitors, and digoxin. A good rule of thumb to follow until creatinine clearance can be calculated is to reduce the total dose by half in frail elderly persons or in those with established renal disease. Anticholinergic agents should be used with caution because they are associated with urinary retention, heart block, constipation, dry mouth, blurred vision, sedation, and acute or chronic confusion in elderly patients.

Amiodarone, a class III antiarrhythmic, has become the drug of choice for the management of supraventricular and ventricular arrhythmias.1,2 Although not an FDA- approved indication, the use of amiodarone to treat atrial fibrillation is supported by practice guidelines from the American College of Cardiology/ American Heart Association (AHA) and the European Society of Cardiology.

SAN FRANCISCO -- Older men with limited life expectancies are getting screened much too often for prostate cancer, given the potential harm that may follow a positive test versus the likelihood of benefit, researchers here reported.

NEW YORK -- Uncomplicated diabetes does not affect 10-year heart transplant survival, but patients with diabetes-related renal disease or stroke do not do as well, reported surgeons here.

ROCHESTER, Minn. -- Mortality rates for heart failure patients with preserved left ventricular ejection fraction (non-systolic) are similar to those for patients with a reduced ejection fraction (systolic). However, a higher systolic pressure on admission was a marker of better prognosis.

Abstract: Our understanding of the pathobiology of pulmonary arterial hypertension (PAH) has evolved considerably over the past 2 decades, with increasing recognition of the important role that aberrant vasoproliferative responses play in conjunction with disordered vasoconstriction. Classification of the many forms of PAH into categories sharing a similar pathophysiology and clinical presentations help the practicing clinician approach a complex differential diagnosis. Noninvasive tests can be used to narrow this differential but must be applied with an appreciation for their limitations. Transthoracic echocardiography is the screening tool of choice; the workup should also include chest radiography and electrocardiography. However, right heart catheterization is ultimately required to establish the diagnosis. While PAH remains a progressive and generally fatal disease, existing therapies have a significant impact on survival and new therapeutic targets offer great hope for improving the prognosis. (J Respir Dis. 2006;27(11):487-493)

ABSTRACT: Establishing the time of symptom onset is essential to selecting the appropriate therapy. Intravenous tissue-type plasminogen activator (t-PA), administered within 3 hours of symptom onset, is the only FDA-approved treatment for acute ischemic stroke. Intra-arterial and combined intra-arterial-intravenous thrombolytic therapy may be considered for patients whose condition does not improve or who present within 3 to 6 hours of symptom onset. Other options for treating acute ischemic stroke are balloon angioplasty with or without stenting (for symptomatic patients with more than 50% intracranial stenosis in whom medical therapy has failed) and mechanical clot retrieval (for those with an NIH Stroke Scale score greater than 10 who present after the 3-hour window for intravenous t-PA and can be treated within 8 hours of symptom onset or who present within 3 hours of symptom onset but in whom intravenous thrombolysis is contraindicated).

THECASE:An 84-year-old man with a history of stable angina, type 2 diabetes, hyperlipidemia, and hypertension presents to the emergency department with worsening dyspnea and peripheral edema. Congestive heart failure is diagnosed, and the patient is admitted to the care of a hospitalist. A standard therapeutic regimen, including diuretics, angiotensin-converting enzyme inhibitors, and oxygen, is instituted, in addition to the patient's home regimen of isosorbide mononitrate, glipizide, and amlodipine. The hospitalsubstitutes pravastatin for the patient's atorvastatin. A Foley catheter is inserted by a urologist because of the patient's benign prostatic hypertrophy. The patient complains of insomnia and is given diphenhydramine. His hospital course is otherwise uneventful.

If Rip Van Winkle were a primary care physician who fell asleep a generation ago and woke up today, what would he think? He would have missed the arrival of managed care. He wouldn't know what a hospitalist does. He might ask how this evasive concept called quality is measured . . . and then cringe at the idea of "report cards" and "pay for performance."

ABSTRACT: Establishing the time of symptom onset is essential to selecting the appropriate therapy. Intravenous tissue-type plasminogen activator (t-PA), administered within 3 hours of symptom onset, is the only FDA-approved treatment for acute ischemic stroke. Intra-arterial and combined intra-arterial-intravenous thrombolytic therapy may be considered for patients whose condition does not improve or who present within 3 to 6 hours of symptom onset. Other options for treating acute ischemic stroke are balloon angioplasty with or without stenting (for symptomatic patients with more than 50% intracranial stenosis in whom medical therapy has failed) and mechanical clot retrieval (for those with an NIH Stroke Scale score greater than 10 who present after the 3-hour window for intravenous t-PA and can be treated within 8 hours of symptom onset or who present within 3 hours of symptom onset but in whom intravenous thrombolysis is contraindicated).