Rev Cardiovasc Med
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Review
An update on antithrombotic therapy in atrial fibrillation: the role of newer and emergent drugs.
Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with potentially dreadful cardioembolic complications such as stroke. The risk of stroke is stratified based on the patient's comorbid conditions using several scoring systems. Patients are treated with oral anticoagulation using warfarin or aspirin based on their cardioembolic stroke risk. Although warfarin has been the only effective therapy, it is underutilized clinically due to concern for multiple drug-to-drug and drug-to-food interactions and hemorrhagic complications. ⋯ There are several other direct factor Xa inhibitors currently under study. Dabigatran may be considered in AF patients who are intolerant to warfarin or unwilling or unable to follow-up with frequent laboratory monitoring. Other newer anticoagulant agents also provide us with possible suitable alternatives to warfarin, and their clinical use will depend on the results from ongoing studies.
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Extrinsic compression due to pulmonary artery enlargement from severe pulmonary hypertension is an uncommon cause of hemodynamically significant left main artery stenosis. Patients with severe pulmonary hypertension who experience angina should be evaluated for possible extrinsic compression of the left main artery due to pulmonary artery enlargement. Although computed tomographic angiography and cardiac magnetic resonance imaging are helpful in the screening for extrinsic left main artery compression, coronary angiography is the gold standard for the diagnosis. Percutaneous coronary intervention of the left main artery is feasible, safe, and a reasonable initial revascularization strategy for these patients because of the high risk of postoperative right ventricular failure and mortality observed with bypass surgery.
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Patients with resistant hypertension have a higher incidence of secondary causes of hypertension compared with the general hypertensive population. It is important to screen such patients for secondary causes of hypertension because appropriate treatment can lead to improved blood pressure control or even cure these patients, and thus avoid the cardiovascular morbidity and mortality associated with uncontrolled hypertension. One common cause of secondary hypertension, often associated with hypokalemia, is primary hyperaldosteronism or Conn syndrome. ⋯ Once the diagnosis of primary aldosteronism is made, it is necessary to determine if aldosterone production is unilateral or bilateral. When production is unilateral (most often from a functional adenoma), surgery is potentially curative. The authors report a case and review the diagnostic workup of Conn syndrome in which resistant hypertension and hypokalemia were cured by unilateral adrenalectomy.
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Review Case Reports
A review of electrocardiography in pulmonary embolism: recognizing pulmonary embolus masquerading as ST-elevation myocardial infarction.
A 64-year-old woman with hypertension and diabetes presented with acute shortness of breath and left-sides chest discomfort. Electrocardiopgram (ECG) demonstrated Q waves, coved ST-segment elevations, and T-wave inversions in leads V₁-V₄, suggesting acute anterior ST-elevation myocardial infarction (STEMI). catheterization revealed nonocclusive coronary artery disease with elevated pulmonary and right heart pressures, confirmed by echocardiography. Ventilation perfusion scan was deemed high probability for pulmonary embolism (PE). ⋯ This case exemplifies similarities in clinical presentation of PE and acute STEMI. The presence of Q waves in anterior leads wih coved ST-elevation after PE has not been described previously. We review the differential diagnosis of ST elevation and the assorted spectrum of ECG changes seen in PE.