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I. Esiel. Hobart and William Smith Colleges.

An even Operative Technique worse error consists in putting the left index finger under- neath the back of the anastomosis while inserting the ante- Small Bowel Anastomosis by Suturing rior seromuscular sutures purchase cialis super active 20 mg amex. Both errors make it possible to pass the seromuscular suture through the bowel lumen and Incision catch a portion of the posterior wall discount 20 mg cialis super active. When the sutures are Use a midline vertical incision for the best exposure of the tied discount cialis super active online american express, an obstruction is created purchase cialis super active 20 mg otc. To prevent this complication, simply have Division of Mesentery the assistant grasp the tails of the anastomotic sutures that have already been tied. Skyward traction on these sutures Expose the segment of intestine to be resected by laying it keeps the lumen of the anastomosis open while the sur- flat on a moist gauze pad on the abdominal wall. Apply stretches the bowel wall, so it becomes relatively thin, medium-size hemostats in pairs to the intervening tissue. After the wedge of mesentery has been completely freed, distal , should be loosely placed in the operative field. After the first seromuscular bite has been taken, the nee- Apply noncrushing intestinal clamps proximally and distally dle is ready to be reinserted into the wall of the opposite to prevent spillage of intestinal contents. At this time it is often helpful to use eased segment of intestine by scalpel division. Elevation relaxes this segment of the Open Two-Layer Anastomosis bowel and permits the suture to catch a substantial bite of Considerable manipulative trauma to the bowel wall can be tissue, including the submucosa. Each bite should encom- avoided if the anterior seromuscular layer of sutures is the pass about 4–5 mm of tissue. First, use 4-0 silk on an atraumatic 43 Small Bowel Resection and Anastomosis 397 needle, and insert a seromuscular suture on the antimesen- and 43. Turning in the corners with this technique is sim- teric border followed by a second suture on the mesenteric ple. Then, complete the final mucosal between these two sutures, and insert and tie the third layer using the Connell technique or a continuous Cushing Lembert suture at this point. After this mucosal layer has been com- anterior seromuscular layer has been completed (Fig. Rotate the bowel by passing guy suture A sive bisection is not necessary in the final layer because the behind the anastomosis (Fig. Tie the suture and close the posterior layer, one wall of the intestine through the anastomosis with the tip which should include the mucosa and a bit of seromuscu- of the index finger. Cut the tails of all the sutures except the two at the end and rotate the bowel to expose the opposite, unsutured bowel (Fig. Approximate this too with interrupted 4-0 silk seromuscular Lembert sutures, paying special attention to the mesenteric border, where fat and blood vessels may hide the seromuscular tissue from view if the dissection has not been thorough. Alternatively, instead of Lembert sutures, “seromuco- sal” stitches may be inserted (Fig. This suture enters the seromuscular layer and, like the Lembert sutures, penetrates the submucosa; but instead of emerging from Fig. Small Bowel Anastomosis Using Stapling Technique In our experience, the most efficient method for stapling the small bowel is a two-step functional end-to-end technique. Insert a cutting linear stapling device, one fork in the proximal and the other fork in the distal segment of the intes- tine (Fig. Fire the stapling instrument, which forms one layer of the anastomosis in an inverting fashion (Fig. Close the remaining defect in the anastomosis in an everting fashion after applying four or five Allis clamps to maintain apposition of the walls of the proximal and distal segments of bowel (Fig. After all the Allis clamps have been aligned, staple the bowel in eversion by applying a 90/3. It is essential that the line of staples cross the cut edge of the serosa and underlying mucosa. This both the anterior and posterior terminations of the anastomotic stitch has the advantage of inverting a smaller cuff of tis- staple line to avoid gaps in the staple line. Fire the stapler, and sue than does the Lembert or Cushing technique and may excise the redundant bowel flush with the stapling device using therefore be useful when the small bowel lumen is exceed- Mayo scissors. When inserted properly the seromucosal Carefully inspect the staple line to be sure each staple has suture inverts the mucosa but not to the extent seen with formed a proper B. If feasible, cover the everted mucosa by the mesenteric suture line to minimize the possibility of it becoming a nidus of adhesion formation. Chassin† Indications Enter the abdomen through a scar-free area and carefully dissect the bowel from the underside of the abdominal Enterolysis is indicated for acute cases of complete small wall. The additional exposure gained by doing the easy dissection first facilitates work in the more difficult parts. Work on the collapsed region Preoperative Preparation (distal to the obstruction) first, if possible, and keep the dilated proximal bowel in the abdomen as long as possible. After all adhesions have been freed, repair any injured seg- Initiate fluid and electrolyte resuscitation. Pitfalls and Danger Points Documentation Basics Inadvertent laceration and spillage of the contents of the • Note findings intestine is a hazard of this procedure. Failure to identify and • Presence or absence of obstruction relieve all points of obstruction can occur unless the entire small bowel is dissected free. Operative Technique Operative Strategy Incision and Bowel Mobilization Dissect carefully and patiently to avoid spillage of intesti- A long midline incision is preferable. Bacterial overgrowth occurs rapidly when the ous midline incision, start the new incision 3–5 cm cephalad contents stagnate. Massive distension with thinning of the to the upper margin of the scar so the abdomen can be entered bowel makes it much more likely to occur and more serious through virgin territory. To avoid this mishap, dissection soon as the peritoneum is entered, air flows into the perito- should be done carefully and patiently. The basic dissection strategy consists in entering the At the same time, dissect away any adherent segments of abdominal cavity through a scar-free area. Access to the peritoneal cavity through an unscarred area often gives the surgeon an opportunity to Whereas the content of the normal small intestine is sterile, assess the location of adhesions in the vicinity of the antici- with intestinal obstruction, the stagnation of bowel content pated incision. After the free abdominal cavity is entered and results in overgrowth of virulent bacteria with production of any adherent segments of intestine are freed, the remainder toxins. When these substances spill into the peritoneal cavity, of the incision is carefully done. Metzenbaum scissors can generally then be insinu- ated behind the various layers of avascular adhesions to incise them (Fig. If the left index finger can be passed underneath a loop of bowel adherent to the abdominal wall, it helps guide the dissection. The aim is to free all the intes- tine from the anterior and lateral abdominal wall, first on one side of the incision and then on the other, so the anterior and lateral layers of parietal peritoneum are completely free of intestinal attachments (Fig. Once the intestine has been freed, trace a normal-look- ing segment to the nearest adhesion. If possible, insert an index finger into the leaves of the mesentery, separating the two adherent limbs of the intestine. By gently bringing the index finger up between the leaves of the mesentery, the adherent layer can often be stretched into a fine, filmy membrane, which is then easily divided with scissors Fig. Chassin the left index finger or closed blunt-tipped curved between the thumb and index finger without damaging the Metzenbaum scissors underneath an adhesion to delineate serosa of the bowel. If this principle is always followed, the dif- Operative Intestinal Decompression ficult portion of a dissection becomes easy. Avoid tackling a dense adherent mass directly; if the loops of intestine If the diameter of the small bowel appears to be so distended going to and coming from the adherent mass are dissected that closing the incision would be difficult, operative decom- on their way in and on their way out of the mass of adhe- pression of the bowel makes the abdominal closure simpler sions, a sometimes confusing collection of intestine can be and may improve the patient’s postoperative course. Decompression may also lessen the risk of inadvertent lac- In the case of an acute small bowel obstruction, frequently eration of the tensely distended intestine. When this occurs, be careful not to 270-cm-long tube with a 5 ml balloon at its tip, for this pro- permit the distended bowel to leap out of a small portion of cedure. It may be passed through the patient’s nose by the the incision, as it may be torn inadvertently in the process. If anesthesiologist or introduced by the surgeon through a possible, first deliver the collapsed bowel (distal to the point Stamm gastrostomy. It is then passed through the pylorus of obstruction), and then trace it retrograde up to the point of with the balloon deflated. The adhesion can then be divided under direct and the tube milked around the duodenum to the ligament of vision and the entire bowel freed.

Unless a large tumor precludes access purchase cialis super active 20mg fast delivery, transect the right hepatic vein with a vascu- lar stapler (McEntee and Nagorney 1991) and ligate the parenchymal side with a running vascular suture before parenchymal transection (Fig cheap cialis super active amex. Alternatively purchase genuine cialis super active, ligate the right hepatic vein as the final step of a formal lobectomy after parenchymal transection cialis super active 20mg overnight delivery. As the hilus is approached, the bile ducts to the lobe being resected are exposed. Again, ligation is performed only when patency of the remaining lobar duct can be ensured. Look for the smaller ducts to segment 1 posterior to the main ductal con- fluence, and ligate them if encountered. Chassin inferior vena cava, to expose the anterior surface of the infe- inal wall. Continue parenchymal transection along the mated to prevent torsion of the liver remnant and postoperative principal plane until the main hepatic veins are encountered. The omentum is not attached to the If the major hepatic vein has been ligated, simply remove the parenchyma. Use inflow vascular occlusion during parenchymal transection to reduce intraoperative hemorrhage if necessary. Anatomic Left Hepatectomy (Left Hepatic Obtain hemostasis and bile stasis but avoid large inter- Lobectomy) locking parenchymal liver sutures. A suction drain is placed adjacent to the transected used for the anatomic right hepatic lobectomy, first identify liver surface and bought out dependently through the abdom- and divide the left hepatic artery and portal vein. After divi- sion of the gastrohepatic omentum, approach the left hepatic artery through the lesser sac via the left lateral aspect of the hepatoduodenal ligament. The main left hepatic artery is gen- erally found just inferior to the base of the round ligament as it enters the left lobe between segments 3 and 4 (Fig. An accessory left hepatic artery, arising from the left gastric artery, always courses through the gastrohepatic omentum and is often divided during division of the gastrohepatic omentum. Confirm the patency of the arterial supply to the right liver by temporarily occluding the left hepatic artery before clamping, ligating, and dividing the vessel (Fig. While retracting the bile duct with a vein retractor, iden- tify the left portal vein at the left aspect of the hepatoduode- nal ligament. The main left portal vein branch always bifurcates from the right main branch at approximately 90° and courses anterolaterally. Note the developing line of transection, as the left liver lobe should now be completely devascularized. If the ductal anatomy is clear, double-ligate and divide the left hepatic duct (Fig. As the veins are ligated and divided, segment 1 can be retracted anteri- orly, and the remainder of the hepatic veins between the infe- rior vena cava and caudate lobe can be divided safely. Division of the retrocaval ligament from the left side of the inferior vena cava allows complete mobilization of segment 1. Mild acidosis and coagulation abnormalities are common and need not be treated unless symptomatic. Nasogastric intuba- tion is continued overnight to prevent the risk of aspiration. Epidural analgesia postoperatively markedly improves pul- monary function and pain control. In contrast to right hepatic lobectomy, postpone ligation of the main left hepatic vein until parenchymal tran- The major complications of hepatic resection are hemorrhage, section is complete because extrahepatic exposure is gener- biliary fistula, intra-abdominal infection, and liver failure. Ligate the short, direct, hepatic veins All complications are best treated by careful intraoperative 790 C. Nagorney’s A comprehensive meta-regression analysis on outcome of anatomic previous contribution. Optimal abdominal incision for partial hepatectomy: increased late complications with References Mercedes-type incisions compared to extended right subcostal inci- sions. Left hepatic trisegmentec- tion criteria for hepatectomy, and role for adjuvant therapy. Early hepatic regeneration index and completeness of regeneration at 6 months Belghiti J, Noun R, Zante E, Ballet T, Sauvanet A. Chassin† Surgical Anatomy Adequate exposure of the body and tail of pancreas requires wide entry into the lesser sac. This is best accom- The pancreas lies in a relatively protected and inaccessible plished by opening the gastrocolic omentum and reflecting location in the upper abdomen. To elevate the body and tail of the nestles in the C-loop of the duodenum, and the body and tail pancreas, incise the peritoneum along the inferior aspect of drape over the retroperitoneum, extending out toward the the pancreas. The head and neck are supplied by the anterior Kocher maneuver to elevate the duodenum and head of pan- and posterior pancreaticoduodenal arches (which form anas- creas and palpate the head. Regional lymph nodes include the superior and inferior Pancreatic injuries are uncommon because of the relatively pancreaticoduodenal nodes; the celiac, hepatic, and superior sheltered position of the gland. Blunt trauma to the upper mesenteric nodes; the superior pancreatic nodes (which drain abdomen may result in pancreatic contusion or complete the body and tail); and the splenic nodes. The main pancreas are usually accompanied by injuries to overlying pattern duct usually receives contributions from both the viscera and major vascular structures – stomach, duodenum, dorsal and ventral anlage, but variations abound. Chassin laparotomy; obtaining temporary hemostasis, control of bile Pseudocysts are often associated with chronic and gastrointestinal leakage, and other temporizing pancreatitis. Adequate relief of pain generally requires that maneuvers may allow resection to be done more safely at a both the pseudocyst and the underlying chronic pancreatitis second procedure when the patient is in better condition. Chronic Pancreatitis Treatment of Chronic Pancreatitis Diagnosis The typical patient with chronic pancreatitis generally requires a period of intensive medical therapy before any The diagnosis of chronic pancreatitis depends on a combina- consideration for surgery. Narcotic dependence is common tion of episodic or daily moderate to severe upper abdominal and may be complicated by alcohol dependence or abuse pain radiating to the back associated with structural or func- which often causes the disease. Such derangements dis- mon owing to exocrine or endocrine failure or to severe post- tinguish this entity from recurring acute pancreatitis or from prandial pain. Unrelenting abdominal pain may occur daily, diagnostic modality, followed by targeted studies designed requiring chronic narcotic use. Some patients have daily pain without exacerbations, many Secondary ductula r ectasia, changes seen only in the side have both, and certain patients have intermittent attacks only. As medications, and oral enzyme supplementation have all been the disease progresses, areas of stricture and dilatation are used for pain relief in the past. Endoscopic stenting is being investigated; it appears to both demonstrate changes well. The degree of dilatation var- provide temporary relief in some patients and may be predic- ies, in some cases resembling a cystic mass and in others tive of results after operative decompression. A mass effect is common and may reach the The indications for surgery are severe, unrelenting extreme of a mass in the head of the pancreas measuring abdominal pain, in most cases resulting in narcotic depen- 10 cm in diameter. The need for intermittent hospitalization is another the pancreas is generally reserved for patients with a mass important indicator supporting the use of invasive, poten- >5 cm in diameter. It is generally advised that patients approximately 60 % of patients with chronic pancreatitis. Secondary narrowing of the terminal common bile duct may be found in 30–50 % of patients, accompanied by sig- Choice of Operation nificant proximal ductal dilatation. Typically the alkaline In general terms the operative procedures for chronic pan- phosphatase is markedly elevated but the bilirubin is normal. The primary goal of each of these opera- There is significant geographic variation in incidence and tive procedures is pain relief. Pancreaticoduodenectomy, manifestations, and this must be kept in mind when reports typically performed as pylorus-preserving resection of the from other parts of the world are evaluated. Indications for dominant mass associated with chronic pancreatitis appears pancreaticoduodenectomy are the symptoms previously to be far more common in middle Europe than in the United described combined with a dominant mass in the head of States, and hence, resectional therapy is more routine there. Resection is also considered reasonable after failure and resectional therapy predominates there. Dilated ducts of a previous drainage procedure and is advocated in patients with a variably significant mass and head of the pancreas with a so-called small duct variance of chronic pancreatitis. The specific advantages suggested for duodenum 88 Concepts in Surgery of the Pancreas 795 preservation include enhanced nutritional status and better Successful outcomes after a Puestow procedure appear to gastric emptying.

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These joints are affected in an oligoarticular-asymmetric or monoarticular pattern discount cialis super active uk. Because the cartilage fails and there is increased pressure on articular bone order cialis super active with american express, joint pain increases with exercise and is relieved by rest cheap cialis super active master card. Therapy is palliative because no agent has been shown to change the natural course of the disease cheap 20 mg cialis super active amex. Design physical therapy and exercise programs which maintain range of motion, strengthen periarticular muscles, and improve physical fitness. In double-blinded placebo trials, there was no difference in relief of joint pain among acetaminophen (4,000 mg/d), analgesic doses of ibuprofen (1,200 mg/d), and antiinflammatory doses of ibuprofen (2,400 mg/d). Perform orthopedic surgery and joint arthroplasty only when aggressive medical treatment has been unsatisfactory, especially if the patient’s quality of life has been decreased. However, its effectiveness has been questioned since a large clinical trial failed to demonstrate superiority over intraarticular injections of saline. In spite of differences in crystal morphology, they have identical clinical presentations and can be distinguished only by synovial fluid analysis. It affects mostly middle-aged men (85%), but women become increasingly susceptible to gout after menopause. As gout becomes chronic, multiple joints may be involved, and deposition of urate crystals in connective tissue (tophi) and kidneys may occur. During an acute attack, serum uric acid may be normal or low, but many people with elevated serum uric acid never develop gout. X-ray of a joint that has been involved in multiple gouty attacks will show erosive calcifications. With acute gouty arthritis, the goal is to decrease inflammation and thus prevent erosion and joint destruction; also in this stage it is very important to avoid fluctuations in serum uric acid level. However, if a patient has been taking allopurinol and an acute attack occurs, do not discontinue. This is usually required for life and initiated in those whose recurrent gouty attacks cannot be corrected by low-purine diet, alcohol limitation, avoiding diuretics, etc. Unlike acute gout, the uric acid level here may help the physician to follow the effect of hypouricemic treatment. Allopurinol can be used in overproducers, undersecretors, or patients with renal failure or kidney stones Febuxostat is used in those intolerant of allopurinol. Pegloticase dissolves uric acid: used in refractory disease Probenecid can be used in the undersecretors (>80% of adults) only. A 32-year-old man comes with a history of right ankle swelling that occurred the night before. On a routine visit the same patient has had 4 documented episodes of gout, despite limiting alcohol and diet. The presence of pseudogout in a patient age <50 should raise suspicions about one of these metabolic abnormalities. Possible acute presentation like gout, or possible asymptomatic and chronic form Knee is most commonly affected joint; other joints commonly affected are the wrist, shoulder, and ankle Definitive diagnosis requires the typical rectangular, rhomboid, positive birefringent crystals on synovial fluid evaluation. X-ray may reveal linear radiodense deposits in joint menisci or articular cartilage (chondrocalcinosis). Examination reveals decreased passive and active range of motion of the right shoulder joint, as well as erythema. The most common cause of infectious arthritis is gonorrhea, and gonococcal arthritis accounts for 70% of episodes in patients age <40. Women are at greater risk during menses and pregnancy, and women 2–3x more likely than men to develop disseminated arthritis. In older patients, Staphylococcus aureus is a common cause of infectious arthritis and occurs in patients with preexisting joint destruction from other rheumatic diseases. Acute bacterial infection may cause rapid cartilage destruction, and thus a patient presenting with monoarticular arthritis needs prompt diagnosis. Further, Staph or Strep must be cleaned out of the joint space by arthrocentesis or arthroscopy. Remember that most infected joints with gonococcal will not have positive cultures, and the Gram stain will be negative. The vasculitis syndromes are stratified according to the types of vessels involved. It typically affects the respiratory tract (sinuses, nose, trachea, and lungs) and kidneys, but can involve any organ system. The most common sign of Wegener granulomatosis is involvement of the upper respiratory tract, which occurs in nearly all patients. A common sign of the disease is chronic rhinitis that does not respond to usual treatment and that becomes increasingly worse. Despite lack of symptoms, lungs are affected in most people; if symptoms are present, they include cough, hemoptysis, and dyspnea. The only way to confirm the diagnosis is with a biopsy of an involved organ (usually nasal septum), demonstrating the presence of vasculitis and granulomas. Standard treatment is combined glucocorticoid plus an immunosuppressive agent (cyclophosphamide). Peripheral neuropathies are very common: tingling, numbness, and/or pain in the hands, arms, feet, and legs, and mononeuritis (e. Diagnosis is made by biopsy of involved organs (most commonly taken from skin, symptomatic nerves, or muscle). Treatment is high doses of corticosteroids and immunosuppressive drugs (cyclophosphamide). The cardinal manifestations of Churg-Strauss are asthma, eosinophilia, and lung involvement. New- onset headache in any patient age >50 prompts consideration of this diagnosis, which if left untreated may result in permanent vision loss. Diagnosis is confirmed by biopsy of the temporal arteries, which will demonstrate the characteristic giant cells. She has never had migraine headaches and denies blurry vision, nausea, or vomiting. The inflammatory myopathies are inflammatory muscle diseases that present with progressive muscle weakness. Patients report difficulty with tasks that involve the proximal muscles: lifting objects, combing hair, getting up from a chair. Ocular muscles are never involved (this feature differentiates the inflammatory myopathies from myasthenia gravis and Eaton-Lambert syndrome). Dermatomyositis will also have skin involvement; the heliotrope rash is a purple-lilac discoloration of the face, eyelids, and sun-exposed areas of the body. These are the most sensitive tests to perform in patients suspected of an inflammatory myopathy. Autoantibodies (anti-Jo-1) occur in patients with inflammatory myopathies, supporting a possible autoimmune origin. Electromyography shows evidence of myopathic potentials characterized by short-duration, low-amplitude units. Clinical Recall A 55-year-old man comes to the outpatient clinic complaining of right toe pain for the past 8 hours. Both dysphagia and odynophagia will cause weight loss if symptoms persist for more than a few days. Evaluation includes select videofluoroscopy (modified barium swallow); the patient swallows food under fluoroscopy and the upper esophageal sphincter is evaluated as the initial swallow is made. Patients with this condition present with: Coughing with swallowing Choking Nasal regurgitation with fluids Aspiration while swallowing Patients with esophageal dysphagia report food “sticking” or discomfort in the retrosternal region. She has had this problem for almost a year, and it is most difficult for her to eat solids. Her symptoms have not worsened at all over this time period, and her weight has been stable. A very small number can be from Chagas disease, gastric carcinoma, or a disease that can infiltrate into the area such as lymphoma. Achalasia presents with progressive dysphagia to both solids and liquids simultaneously and can have regurgitation several hours after eating. This is different from esophageal cancer, which not only usually presents with dysphagia to solid foods and progresses to difficulty swallowing liquids, but also is more common in older patients with a long history of alcohol and tobacco use. Heme-positive stools, >6-month duration of symptoms, and weight loss will confirm diagnosis. Barium esophagography is very accurate and shows dilation of the esophagus, which narrows into a “bird’s beak” at the distal end.

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Also discount 20mg cialis super active, the antihypertensive effect of beta blockers generic cialis super active 20 mg otc, alpha blockers discount cialis super active 20 mg overnight delivery, and nitroglycerin may cause significant hypotension during exercise generic cialis super active 20 mg overnight delivery. A number of other situations or conditions may reduce the validity of the exercise stress test. She has no history of chest pain, and she exercises routinely (runs 2–3 miles per day, 3 times per week). Other types of stress tests include: Nuclear stress test: A radioactive substance is injected into the patient and perfusion of heart tissue is visualized. An abnormal amount of thallium will be seen in those areas of the heart that have a decreased blood supply. Compared to regular stress tests, the nuclear stress tests have higher sensitivity and specificity (92% sensitivity, 95% specificity vs. The latter can recognize abnormal movement of the walls of the left ventricle (wall motion abnormalities) that are induced by exercise. Invasive techniques: Cardiac catheterization is also used in patients with stable angina for (1) diagnosis and (2) prognosis/risk stratification. Angiography is an appropriate diagnostic test when noninvasive tests are contraindicated or inadequate due to the patient’s illness or physical characteristics (e. Cardiac angiography is also used after conventional stress tests are positive to identify patients that will benefit from stent placement or bypass surgery. Other medications patients with stable angina should be taking, unless contraindicated, include aspirin and statins (for lipid lowering). Also, modify the risk factors (tobacco cessation, exercise, control of hypertension, etc. Most patients will require both pharmacologic and nonpharmacologic interventions to reach target goals. These are patients with established cardiovascular disease plus diabetes and patients with acute coronary syndromes. Every effort should be made to ensure that patients with coronary artery disease receive optimal lipid therapy. Statin medications are strongly supported as first- line medications due to compelling evidence of mortality reduction from multiple clinical trials. Typically, this means patients with left main disease or triple-vessel disease and low ejection fraction. The procedure involves the construction of 1 or more grafts between the arterial and coronary circulations. Potential consequences of graft failure (loss of patency) include the development of angina, myocardial infarction, or cardiac death. Collectively they represent one of the most common causes of acute medical admission to U. The natural course of coronary atherosclerotic plaque development and subsequent occlusion does not proceed in a step-wise, uniform manner, gradually progressing to luminal obstruction (and symptoms) over many years. Sudden change in the pattern of angina usually means a physical change within the coronary arteries, such as hemorrhage into an atherosclerotic plaque or rupture of a plaque with intermittent thrombus formation. High-risk patients should be treated with aggressive medical management and arrangements should be made for coronary angiography and possible revascularization, except in those with severe comorbidities. Medical management Aspirin is recommended (unless contraindicated) in all patients. Antiplatelet therapy (beyond aspirin): Early treatment should be initiated with aspirin and clopidogrel, prasugrel, or ticagrelor with the following considerations: Avoid clopidogrel in patients likely to require emergency coronary bypass surgery. Antithrombin therapy: Give unfractionated heparin or subcutaneous enoxaparin until angiography or for 48–72 hours. Give beta blockers on admission unless there are contraindications (severe asthma or cardiogenic shock). The use of these agents provides a more comprehensive platelet blockade than the combination of aspirin and heparin alone. Concomitant tirofiban is particularly beneficial and recommended in patients with diabetes. In patients with diabetes, good glycemic control should be targeted in the hospital and after discharge. Pain or ischemia refractory to medical therapy and high-risk features on early exercise testing can also identify patients suitable for early invasive therapy. Clinical Recall Which of the following medications must be withheld before performing an exercise stress test? Often, the pain is accompanied by additional symptoms, such as dizziness (lightheadedness), nausea or vomiting, diaphoresis, or shortness of breath (dyspnea). Women, elderly, and diabetic patients are prone to atypical symptoms such as nausea or dyspnea as the sole symptoms of infarction. Pulse rate may be normal, but often bradycardia is present in inferior infarctions. Restoring coronary patency (emergency reperfusion) as promptly as possible is a key determinant of short-term and long-term outcomes. Prolonged persistence of antibodies to streptokinase may reduce the effectiveness of subsequent treatment; therefore, streptokinase should not be used if used within the previous 12 months in the same patient. In patients selected for fibrinolytic therapy, clopidogrel should be given in addition to aspirin, unless contraindicated. Clopidogrel should be continued for at least a month after fibrinolytic therapy, or for up to 9–12 months after stent implantation, depending on the type of stent used. It may be advisable to give a bolus of heparin while the patient is in transit to the catheterization laboratory. With fibrinolysis: Antithrombin therapy should be used with fibrin-specific fibrinolytic agents. There is no significant advantage over full-dose fibrinolytic therapy alone, and the risk of bleeding is increased, particularly in the elderly. Clopidogrel: There is evidence that clopidogrel or prasugrel should be prescribed for up to 9–12 months after acute myocardial infarction, particularly after stent placement. Clopidogrel may also be prescribed as an alternative when aspirin is contraindicated, or to those intolerant to aspirin, in patients with recurrent cardiac events. Its use should be reviewed later on the course of the patient and discontinued if the heart failure resolves. Secondary prevention through the control or elimination of known risk factors for coronary artery disease (e. You are asked by your patient, who has a history of ischemic heart disease, about drug treatments that have been shown to decrease mortality in his case. It is used to assess prognosis and to identify those patients with reversible ischemia who should then have an angiogram (if one has not been done) to assess the need for coronary artery bypass graft. Myocardial perfusion imaging can be performed before hospital discharge to assess the extent of residual ischemia if the patient has not already undergone cardiac catheterization and angiography. Thromboembolic Mural thrombus with systemic embolism Deep vein thrombosis with prolonged immobilization Sudden cardiac death Most often due to arrhythmia. Beyond the accompanying emotional distress and suffering, depression also increases one’s risk of having another heart attack or dying over the ensuing months and years. Cognitive behavior therapy has also been found to be effective in treating depression. Cocaine use has been documented to induce coronary vasoconstriction in nondiseased coronary segments but is more pronounced in atherosclerotic segments. As opposed to typical angina, Prinzmetal angina usually occurs during periods of rest, most often at night and in the early morning hours. In men, Prinzmetal angina is often associated with atherosclerosis; in women it is not. Ergonovine has been used to trigger coronary artery spasm in susceptible patients, confirming the diagnosis. Treatment with calcium channel blockers or nitrates eliminates spasm in most of these patients. Clinical Recall Which of the following is not an absolute contraindication to thrombolytic therapy? Case 1: A 62-year-old man with hypertension and dyslipidemia presents with dyspnea and lower-extremity edema for 2 months. The echocardiogram shows a dilated left ventricle with an ejection fraction of 35%.

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