Current problems in cardiology
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Pulmonary embolism (PE) is a common problem. Given the significant overlap of symptoms and signs between the presentation of PE and acute coronary syndromes, it becomes clear that cardiologists must be familiar with the diagnosis and treatment of PE. The critical issue is always to consider PE in the diagnosis of chest pain. ⋯ The cornerstone of treatment includes anticoagulation. For patients with massive or submassive PE, thrombolysis and embolectomy should be considered. Finally, both primary and secondary prevention are critical to the long-term health of the patient.
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Hypertrophic cardiomyopathy is a fascinating disease of marked heterogeneity. Hypertrophic cardiomyopathy was originally characterized by massive myocardial hypertrophy in the absence of known cause, a dynamic left ventricular outflow obstruction, and increased risk of sudden death. It is now well accepted that multiple mutations in genes encoding for the cardiac sarcomere are responsible for the disease. Complex morphologic and pathophysiological differences, disparate natural history studies, and novel treatment strategies underscore the challenge to the practicing cardiologist when faced with the management of the patient with hypertrophic cardiomyopathy.
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The recognition, evaluation and treatment of patent foramen ovale has attracted increasing interest as the importance and frequency of paradoxical embolism has become better understood. The interest in this field has been driven largely by the widespread application of echocardiography with identification of a patent foramen ovale and/or an atrial septal aneurysm. The evaluation of the role of a patent foramen ovale in patients with a neurologic event is complex because the patent foramen ovale or atrial septal aneurysm may either be an innocent bystander or could be the etiologic mechanisms involved in the paradoxical embolus. ⋯ The field continues to change with new technology being developed and with new applications. A recently exciting finding has been the identification that closure of a patent foramen ovale may be associated with dramatic improvement in symptoms of patients with disabling migraine headaches. Other potential applications of these devices include those patients who are deep-sea divers, in whom the potential for "bends" exists, or high altitude airplane pilots.
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The general trend in the recent literature has been to highlight the difficulties and shortcomings of the physical examination and to attribute these difficulties to deficiencies in training rather than to intrinsic weaknesses in auscultation itself. The call is for better training. Given the advice of the authors mentioned above, individual training may be warranted at the postgraduate level and in the large community of practicing internists and cardiologists. ⋯ Later, with the advent of commercially available CD-ROM devices, newer, better-integrated teaching devices have been developed, some of them outstanding in their clarity and quality. Despite the obvious value of such instructional aids that are best used in the individual setting, there is evidence that the classroom is still of significant value in teaching auscultation. However, nowhere else in the practice of medicine is a mentor approach more valuable than in learning auscultation. (ABSTRACT TRUNCATED)