Faculty Bibliography

Direct percutaneous transluminal coronary angioplasty has recently shown better results than thrombolysis in reestablishing normal arterial flow following an acute myocardial infarction (MI). Because many patients do not have timely access to well-established cardiac catheterization facilities, however, optimizing the use of thrombolytic agents, as well as adjuvant therapies that inhibit the prothrombotic process, remains an essential strategy. Prescribe chewed aspirin for all patients with acute MI; also give heparin with recombinant tissue-type plasminogen activator and pharmacologically similar thrombolytics. Low molecular weight heparin is easier to use than the unfractionated drug may reduce the risk of reinfarction. Newer and investigational antiplatelet and antithrombin agents (such as abciximab and bivalirudin) have yielded evidence of improved arterial patency with fewer hemorrhagic complications

Thrombolytic therapy is lifesaving in patients with acute myocardial infarction who present within 12 hours of symptom onset, have ECG signs of ST-segment elevation or new left bundle branch block, and have no contraindications to thrombolysis (such as internal bleeding, recent major surgery or trauma, intracranial disease, or severe uncontrolled hypertension). Certain patients presenting more than 12 hours after symptom onset also may be candidates for thrombolysis. However, only 54% of patients obtain normal angiographic blood flow with the most aggressive regimen validated to date: accelerated recombinant tissue type plasminogen activator plus aspirin and heparin. Newer and investigational drugs, such as reteplase, lanoteplase, and saruplase, are easier to administer but generally have not yet been shown to be safer or more effective than other thrombolytics

The elderly represent an increasingly important and challenging subset of the population of patients with ischemic heart disease. They are more likely to have comorbid conditions, atypical presentations, and unfavorable outcomes than their younger counterparts. Some of these findings are undoubtedly related to the structural and functional changes in the cardiovascular system associated with aging. The available data suggest that standard pharmacologic, thrombolytic, and definitive revascularization techniques have important roles in the therapy of geriatric patients but have been underused

The purpose of this study was to define the contribution of transesophageal echocardiography to the diagnosis of right atrial tumors in a large series of patients with this rare finding. Transesophageal echocardiography (TEE) has been found to be valuable in evaluating patients with intracardiac masses and has been shown to be superior to transthoracic echocardiography (TTE) in evaluating left heart masses. Between 1989 and 1993, 23 patients with either known tumors elsewhere or right atrial masses that were detected on TTE were evaluated with TEE. TEE studies were performed in the noninvasive cardiology laboratory. All patients were studied with 5 MHz biplane or omniplane transducers. The right atrium was evaluated for the presence, characteristics, extent, and attachment of any masses and for extension of these masses into the great vessels or other cardiac chambers. No complications occurred. Six patients had primary right atrial tumors. In 10 patients the tumors reached the right atrium via the inferior vena cava. Seven patients had malignant secondary tumors. TEE demonstrated three tumors not detected by TTE. Furthermore TEE provided 16 additional findings not seen on TTE. In conclusion, TEE is superior to TTE in the evaluation of right atrial tumors. TEE should be considered in patients with right atrial tumors even when these tumors have been demonstrated with TTE

BACKGROUND: Recent advances in surgical techniques for the repair of left ventricular aneurysms (LVAs) include the use of an endoventricular patch to exclude the aneurysm cavity. This technique has replaced conventional linear plication of the aneurysm. The endoventricular patch technique remodels the left ventricular cavity to a more physiological geometry that improves function. METHODS AND RESULTS: From December 1989 through November 1993, 45 patients underwent an LVA repair with an endoventricular patch. This procedure was performed in association with coronary artery bypass grafting in 40 patients. Twenty-eight patients (62.2%) also had nonguided encircling subendocardial incisions. Operative procedures included 7 emergency operations, 3 concomitant valve procedures, and a mean of 2.2 bypass grafts per patient. Eight patients had previous cardiac operations. Hospital mortality was 15.6% (7/45) for all patients and 9.1% (3/33) for nonemergent revascularization and LVA repairs. Ejection fraction improved from a mean of 25.8% preoperatively to 37.8% postoperatively; the mean New York Heart Association classification improved from 3.5 to 1.5. Of patients known to have preoperative arrhythmias (inducible or sudden death), 69% were not inducible postoperatively without antiarrhythmic medication. Survival from late cardiac death (including death of unknown origin) was 86.5% at 2 years. Freedom from documented ventricular arrhythmias was 94.3% at 2 years. CONCLUSIONS: These results indicate that the patch endoaneurysmorrhaphy technique can provide an excellent functional and physiological outcome in patients with LVAs and severely impaired ventricular function

The elderly represent an increasingly important and challenging subset of the population of patients with ischemic heart disease. They are more likely to have comorbid conditions, atypical presentations, and unfavorable outcomes. Some of these features are undoubtedly related to the structural and functional changes in the cardiovascular system associated with aging. The available data suggest that standard pharmacologic, thrombolytic, and definitive revascularization techniques have important roles in the treatment of these patients, but have been underused

KIE: Results of voluntary, anonymous human immunodeficiency virus (HIV) antibody testing and counseling offered to all patients attending a sexually transmitted disease (STD) clinic showed that men who refused testing were 5.3 times more likely to be infected than men who accepted testing, and that male homosexuals and black and Hispanic men who refused testing were even more likely to be infected than their counterparts who accepted testing. The prevalence of HIV infection in persons refusing HIV testing was determined in a retrospective, blinded study using stored serum specimens originally drawn for syphilis testing. It is recommended that HIV testing and counseling should be routinely offered to STD clinic patients; male STD clinic patients who refuse voluntary HIV testing should be counseled about reducing their risk for HIV transmission. O