By Lawrence M. Tierney, Clinton E. Thompson, Sanjay Saint
Univ. of California, San Francisco. Pocket-sized define covers information at the analysis and remedy of greater than 500 scientific problems. contains tabs for speedy reference. earlier version: c1997. Now contains 'a pearl consistent with page', a geriatrics bankruptcy, and a genetics bankruptcy. Softcover.
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Curr Opin Pulm Med 1995;1:303. [PMID: 9363069] 1 34 Essentials of Diagnosis & Treatment Hypertension 1 ■ Essentials of Diagnosis • In most patients (95% of cases), no cause can be found • Chronic elevation in blood pressure (> 140/90 mm Hg) occurs in 15% of white adults and 30% of black adults in the United States; onset usually between ages 20 and 55 • The pathogenesis is multifactorial: a combination of environmental, dietary, genetic, and neurohormonal factors all contribute • Most patients are asymptomatic; some, however, complain of headache, epistaxis, or blurred vision if hypertension is severe • Most diagnostic study abnormalities are referable to “target organ” damage: heart, kidney, brain, retina, and peripheral arteries ■ Differential Diagnosis Secondary causes of hypertension: • Coarctation of the aorta • Renal insufficiency • Renal artery stenosis • Pheochromocytoma • Cushing’s syndrome • Primary hyperaldosteronism • Chronic use of oral contraceptive pills or alcohol ■ Treatment • Decrease blood pressure with a single agent (if possible) while minimizing side effects • Many recommend diuretics and beta-blockers as initial therapy, but considerable latitude is allowed for individual patients • Other agents useful either alone or in combination include ACE inhibitors, angiotensin II receptor blockers, and calcium channel blockers; α1-blockers are considered second-line agents • If hypertension is unresponsive to medical treatment, evaluate for secondary causes ■ Pearl A disease without a pearl—30 million Americans have it, and no clinical feature is characteristic, either symptomatically or on examination.
Am J Cardiol 1999; 83(5B):161D. [PMID: 10089860] 1 24 Essentials of Diagnosis & Treatment Congestive Heart Failure 1 ■ Essentials of Diagnosis • Two pathophysiologic categories: systolic dysfunction and diastolic dysfunction • Systolic: the ability to pump blood is compromised; ejection fraction is decreased; causes include coronary artery disease, dilated cardiomyopathy, myocarditis, “burned-out” hypertensive heart disease, and valvular heart disease • Diastolic heart unable to relax and allow adequate diastolic filling; normal ejection fraction; causes include ischemia, hypertension with left ventricular hypertrophy, aortic stenosis, hypertrophic cardiomyopathy, restrictive cardiomyopathy, and small vessel disease (eg, diabetes mellitus) • Evidence of both common, but up to 20% of patients will have isolated diastolic dysfunction • Symptoms and signs can result from left-sided failure, right-sided failure, or both • Left ventricular failure: exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pulsus alternans, rales, gallop rhythm; pulmonary venous congestion on chest x-ray • Right ventricular failure: fatigue, malaise, elevated venous pressure, hepatomegaly, and dependent edema • Diagnosis confirmed by echo or pulmonary capillary wedge measurement ■ Differential Diagnosis • Pericardial disease • Nephrosis or cirrhosis • Hypothyroidism ■ Treatment • Systolic dysfunction: vasodilators (ACE inhibitors or combination of hydralazine and isosorbide dinitrate), beta-blockers, spironolactone, and low-sodium diet; for symptoms, use diuretics and digoxin; anticoagulation advocated by many in high-risk patients • Diastolic dysfunction: a negative inotrope (beta-blocker or calcium channel blocker), low-sodium diet, and diuretics for symptoms ■ Pearl Ninety-five percent of right heart failure is caused by left heart failure.
Reference Prystowsky EN: Management of atrial fibrillation: therapeutic options and clinical decisions. Am J Cardiol 2000;85:3D. [PMID: 10822035] 1 18 Essentials of Diagnosis & Treatment Atrial Flutter 1 ■ Essentials of Diagnosis • Especially common in COPD; also seen in dilated cardiomyopathy, especially in alcoholics • Atrial rate between 250 and 350 beats/min with every second, third, or fourth impulse conducted by the ventricle • Patients may be asymptomatic, complain of palpitations, or have evidence of congestive heart failure • Flutter (a) waves visible in the neck in occasional patients • Electrocardiography shows “sawtooth” P waves in V1 and the inferior leads; ventricular response usually regular; less commonly, irregular due to variable atrioventricular block ■ Differential Diagnosis With regular ventricular rate: • Automatic atrial tachycardia • Atrioventricular nodal reentry tachycardia • Sinus tachycardia With irregular ventricular rate: • Atrial fibrillation • Multifocal atrial tachycardia ■ Treatment • • • • Often spontaneously converts to atrial fibrillation Electrical cardioversion is reliable and safe Conversion may also be achieved by drugs (eg, ibutilide) Risk of embolization is lower than for atrial fibrillation, but anticoagulation still recommended • Amiodarone in patients with chronic atrial flutter • Consider radiofrequency ablation in patients with chronic atrial flutter refractory to medical therapy ■ Pearl A regular heart rate of 140–150 in a patient with COPD is flutter until proved otherwise.