Zeitschrift für Kardiologie
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Review Case Reports
Pregnancy-associated spontaneous coronary artery dissection: impact of medical treatment. Case report and systematic review.
We report on a 22- year-old woman with postpartum dissection of the left anterior descending artery and the intermediate branch. The patient was treated with acetylsalicylic acid (ASA), clopidogrel, and betablocker only. Coronary angiography performed 20 months later revealed complete resolution of the dissection sites. ⋯ In 5/16 patients percutaneous coronary intervention (PCI) was performed as first-line therapy. Three patients underwent coronary artery bypass grafting, which was performed primarily in one patient, and secondarily in two patients with persisting dissections and ongoing ischemic symptoms after previous medical treatment or PCI without stenting, respectively. In conclusion, medical treatment including ASA, clopidogrel and betablocker therapy results in an excellent clinical and angiographic result in approximately one third of patients with P-SCAD.
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In patients with heart failure and atrial fibrillation cardiac glycosides, generally in combination with beta-blockers, are indicated to control ventricular rate. In systolic heart failure and sinus rhythm, however, the use of digitalis continues to be debated. There are special concerns that cardiac glycosides might lead to an increased mortality rate in women. ⋯ Beneficial effects of cardiac glycosides in heart failure seem to be related to the attenuation of sympathetic activation and neurohumoral alterations, which is already obtained at low digoxin serum concentrations, while high serum levels are associated with increased mortality. Therefore, in patients with sinus rhythm who remain symptomatic under an optimized therapy with ACE inhibitors, beta-blockers and diuretics in addition to digitalis should be considered regardless of the gender. However, target serum digoxin concentrations should be low in a range of 0.5 to 0.8 ng/ml.
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About half of all deaths are due to cardiovascular disease and its complications. The economic burden on society and the healthcare system from cardiovascular disability, complications, and treatments is huge and becoming larger in the rapidly aging populations of developed countries. As conventional risk factors fail to account for part of the cases, homocysteine, a "new" risk factor, is being viewed with mounting interest. ⋯ Based on various calculation models, reduction of elevated plasma homocysteine concentrations may theoretically prevent up to 25 percent of cardiovascular events. Supplementation is inexpensive, potentially effective, and devoid of adverse effects and, therefore, has an exceptionally favorable benefit/risk ratio. The results of ongoing randomized controlled intervention trials must be available before screening for and treatment of hyperhomocysteinemia can be recommended for the apparently healthy general population.