The Canadian journal of cardiology
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Review Comparative Study
Current status of transmyocardial laser revascularization: review of the literature.
Transmyocardial laser revascularization (TMLR) is a new procedure for the treatment of angina pectoris in which high power laser energy is used to create channels in ischemic myocardium. ⋯ At present, TMLR is potentially indicated for patients with severe angina that is refractory to medical therapy and who have contraindications for the more traditional therapies (coronary artery bypass grafting, percutaneous transluminal coronary angioplasty and transplantation). More data are needed to evaluate fully the indications for this procedure.
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To review prehospital management of patients with suspected ST elevation acute myocardial infarction (AMI) based on the acquisition and interpretation of electrocardiograms (ECGs), and the effects of thrombolytic therapy initiated by prehospital care providers. ⋯ Prehospital treatment of patients with chest pain using ECGs and thrombolysis is safe. Though rural patients have significant reductions in total mortality when treated with thrombolysis in a prehospital setting, this has not been documented with an urban population. Prehospital identification of thrombolysis-eligible patients with ST elevation AMI via acquisition and interpretation of ECGs followed by triage to a hospital 'lytic team' has the potential to improve patient outcome and requires further investigation. A prehospital paramedic program for identifying and treating thrombolysis-eligible patients requires intensive planning, retrospective feasibility work, implementation and monitoring to establish effectiveness.
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Review Comparative Study
The efficacy and safety of combination warfarin and ASA therapy: a systematic review of the literature and update of guidelines.
The English-language literature was systematically reviewed to clarify the role of combination antithrombotic therapy with warfarin and acetylsalicylic acid (ASA) versus monotherapy with either agent, including data from several recently published trials. Sixteen published studies with evaluable efficacy and/or safety data were identified. For patients with prosthetic heart valves at high risk of thromboembolism, combined warfarin and ASA therapy may be beneficial compared with warfarin alone. ⋯ Evidence does not support the use of combined antithrombotic therapy in patients with established ischemic heart disease, ischemic stroke, coronary artery bypass grafts or atrial fibrillation. Combination therapy is associated with an increased risk of minor and major bleeding. The highest dose of ASA that can be recommended in combination with warfarin is 100 mg daily.
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Review Case Reports
Torsade de pointes with sotalol overdose treated successfully with lidocaine.
Torsade de pointes is a polymorphic ventricular tachyarrhythmia associated with a long QT interval. The prognosis is excellent if torsade is recognized early. ⋯ Sotalol overdose causing torsade is reported in which lidocaine appears to have suppressed an episode of torsade as well as prevented further episodes. Current understanding of the electrophysiological mechanisms of torsade and lidocaine, a review of the literature and the author's experience indicate that lidocaine is a potentially useful therapy in torsade.
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This article proposes a modification of a hospital cardiopulmonary resuscitation (CPR)/do not resuscitate (DNR) policy that prescribes CPR for all unless a DNR order is agreed to by patient and physician. Rather than maintaining CPR as an intervention that can be avoided only by a negative order, the proposed modified policy supports a positive order, i.e., perform CPR when beneficial unless the patient refuses. To provide a clinical basis for an ethical discussion comparing the current policy with the modified proposal, a brief review of the outcome of CPR in terms of survival to discharge is presented. ⋯ The modified proposal should provide a more realistic framework within which to evaluate the needs and wishes of patients at this difficult and emotional time. This concept is implemented by establishing the CPR status of all patients as one component of their positive treatment regimen, rather than having CPR as an intervention to be avoided only by the DNR order. The author discusses the current and proposed policy relative to their effect on patient selection, discussion with patients about CPR, the dilemma that results when the patient insists on CPR when it is not recommended and the protection of patient autonomy.