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Congestive Heart Failure
Published in Jahangir Moini, Matthew Adams, Anthony LoGalbo, Complications of Diabetes Mellitus, 2022
Jahangir Moini, Matthew Adams, Anthony LoGalbo
Long-term management for HF is achieved with diuretics, nitrates, digoxin, ACE inhibitors, beta-blockers, aldosterone antagonists, ARBs, and angiotensin receptor/neprilysin inhibitors. If the sodium-glucose co-transporter 2 inhibitor called dapagliflozin is added, it can reduce complications and deaths if the patient has elevated natriuretic peptide levels. It has good effects in patients with diabetes mellitus or without. For arrhythmias, electrolytes are normalized, atrial and ventricular rates are controlled, and antiarrhythmic medications may be administered. For persistent sinus tachycardia, a beta-blocker given in increasing doses may be helpful. Atrial fibrillation with an uncontrolled ventricular rate is treated with a target resting rate being less than 80 beats per minute. Beta-blockers are used first, but rate-limiting calcium channel blockers are used with caution as long as systolic function is preserved. For some patients, digoxin is used to control heart rhythm or rate. A permanent pacemaker must be inserted for some patient.
Cardiology
Published in Faye Hill, Sash Noor, Neel Sharma, Tiago Villanueva, Medical and Surgical Emergencies for Students and Junior Doctors, 2021
Faye Hill, Sash Noor, Neel Sharma
Patients should stop offending medications such as digoxin, calcium channel blockers and beta blockers if currently prescribed. Severely symptomatic patients should undergo transcutaneous pacing. Otherwise, the treatment of choice long term is permanent pacemaker insertion.
Perioperative issues
Published in Neeraj Sethi, R. James A. England, Neil de Zoysa, Head, Neck and Thyroid Surgery, 2020
Gordon A. G. McKenzie, David J. H. Shipway
Intraoperative electrocautery use within 30 cm of pacing devices or leads can interfere with permanent pacemaker function, which requires battery and threshold checks to have been conducted within the last year before surgery. Pacemaker-patients should be referred to cardiac pacing services before surgery to determine if reprogramming is required to allow diathermy. Pacemaker-dependent patients may need their device rendered non-sensing by placing a magnet over the skin of the pacemaker during surgery. Implantable cardioverter defibrillator devices must be deactivated before surgery, continuously monitored intraoperatively and reactivated postoperatively by the cardiac pacing services [9,12].
Leadless cardiac pacing systems: current status and future prospects
Published in Expert Review of Medical Devices, 2019
Niek E. G. Beurskens, Karel T. N. Breeman, Kosse J. Dasselaar, A. Chris Meijer, Anne-Floor B. E. Quast, Fleur V. Y. Tjong, Reinoud E. Knops
Permanent pacemaker therapy remains a necessary treatment in patients with symptomatic bradyarrhythmias. The number of patients globally undergoing pacemaker implantation has increased steadily up to a current annual implant rate of ~1 million devices [1,2]. The implantation rate continues to expand due to an aging population [3]. Pacing therapy results in health-related quality of life improvements and ameliorates prognosis in second-degree type II or third-degree atrioventricular (AV) block [4,5]. Conventional transvenous pacemaker therapy is associated with a concomitant significant risk of complications, which are primarily lead- or pocket-related. Large nationwide multicenter cohort studies conducted in Denmark and the Netherlands demonstrated short-term transvenous pacemaker-related complication rates in 9.5% to 12.6% of patients. Lead-related interventions are the most frequently reported complications followed by pocket hematoma and pneumothorax. Long-term complications occur in an additional 9.2% of patients and consist mainly of lead dislodgment, stimulation threshold problems or discomfort of the pacemaker or pocket. Infection of a permanent implanted pacemaker is uncommon but is considered a serious complication and is associated with substantial morbidity and mortality. Current guidelines recommend complete hardware removal to mitigate the risk for severe systemic infection and infective endocarditis [6–8].
Sutureless Aortic Valve Replacement (AVR) for Prosthetic Valve Endocarditis: A Single Centre Experience
Published in Structural Heart, 2019
Ian Cummings, Michael O. Murphy, John R. Pepper, Ulrich P. Rosendahl, Cesare Quarto, Georgios Asimakopoulos
Results: Eight patients who underwent sutureless AVR (M:F 1:1) with a median age of 66.5 years were included in this analysis. All patients underwent first time re-do sternotomy with four infected mechanical and four bioprosthetic aortic valves being explanted. The median EuroSCORE II was 14.55 (range 5.08 - 46.5). The median cardiopulmonary bypass and cross clamp times were 136 (range 88-549) and 93 (range 59-213) minutes respectively. Four patients underwent additional aortic annulus or root reconstruction requiring multiple pledgeted sutures and/or a pericardial or Dacron patch. Three Small (19-21mm) and five Medium (21-23mm) sized valves were implanted. There was one (12.5%) hospital death in a patient with a EuroSCORE II of 46.5 and one re-exploration. There were no post-operative strokes. One patient required a permanent pacemaker. Pre-discharge echocardiography demonstrated a median trans-valvular mean gradient of 11 mmHg (range 9-35). Median post-operative length of hospital stay was 16 days (range 7-32). None became re-infected.
Multiple admissions to the coronary care unit due to falsely elevated cardiac troponin
Published in Baylor University Medical Center Proceedings, 2018
Mohamed Ayan, Zaid Gheith, Aneesha Ananthula, Mohsin Salih, Srikanth Vallurupalli, Jawahar L. Mehta
A 94-year-old white man was known to have coronary artery disease and had coronary artery bypass grafting at age 88. A permanent pacemaker had been implanted for symptomatic bradycardia. He presented to the hospital with altered mental status and change in behavior. He denied any chest pain or dyspnea. On exam, he was frail. His blood pressure was 130/78 mm Hg; heart rate, 76 beats per minute; respiratory rate, 16 breaths per minute; and pulse oximetry, 95% on room air. His temperature was 98.6°F. Precordial exam disclosed no abnormalities. His chest was clear to auscultation bilaterally. His abdomen was mildly tender on palpation. No neurological abnormalities were noted. Laboratory work revealed a normal hemoglobin of 13 g/dL, a white blood cell count of 9.0 × 103/μL, a platelet count of 141 × 103/μL, and creatinine of 0.7 mg/dL. Importantly, serial cTnI was markedly elevated at 30.8 ng/mL, 29.6 ng/mL, and then 29.9 ng/mL (AccuTnI+3, Beckman Coulter, reference <0.03 ng/mL). Electrocardiogram revealed ventricular paced rhythm unchanged from previous visits. The patient was admitted to the coronary care unit and started on subcutaneous enoxaparin. A transthoracic echocardiogram showed normal left ventricular wall thickness and internal dimensions with no wall motion abnormalities. A urinary tract infection was diagnosed and the patient had an uneventful recovery with antibiotics. Review of records revealed three different admissions to the coronary care unit over the previous 3 years for various noncardiac complaints and similar troponin elevations (all without a rise and fall).