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ABSTRACT: The American College of Radiology has developed appropriateness criteria for a number of clinical conditions and procedures. Criteria are available on imaging tests used in the evaluation of acute chest pain--suspected myocardial ischemia. Imaging tests for a suspected cardiac etiology include transthoracic echocardiography, transesophageal echocardiography, radionuclide perfusion imaging, radionuclide ventriculography, radionuclide infarct avid imaging, and positron emission tomography. If the cardiac ischemic work-up is negative or indeterminate, applicable tests include chest radiography; conventional, multidetector, and electron beam computed tomography; and magnetic resonance imaging. A summary of the criteria, with the advantages and limitations of each test, is presented in this article.
Acute Pericarditis - Article
ABSTRACT: Although acute pericarditis is most often associated with viral infection, it may also be caused by many diseases, drugs, invasive cardiothoracic procedures, and chest trauma. Diagnosing acute pericarditis is often a process of exclusion. A history of abrupt-onset chest pain, the presence of a pericardial friction rub, and changes on electrocardiography suggest acute pericarditis, as do PR-segment depression and upwardly concave ST-segment elevation. Although highly specific for pericarditis, the pericardial friction rub is often absent or transient. Auscultation during end expiration with the patient sitting up and leaning forward increases the likelihood of observing this physical finding. Echocardiography is recommended for most patients to confirm the diagnosis and to exclude tamponade. Outpatient management of select patients with acute pericarditis is an option. Complications may include pericardial effusion with tamponade, recurrence, and chronic constrictive pericarditis. Use of colchicine as an adjunct to conventional nonsteroidal anti-inflammatory drug therapy for acute viral pericarditis may hasten symptom resolution and reduce recurrences.
ABSTRACT: Family physicians commonly care for patients with serious mental illness. Patients with psychotic and bipolar disorders have more comorbid medical conditions and higher mortality rates than patients without serious mental illness. Many medications prescribed for serious mental illness have significant metabolic and cardiovascular adverse effects. Patients treated with second-generation antipsychotics should receive preventive counseling and treatment for obesity, hyperglycemia, diabetes, and hyperlipidemia. First- and second-generation antipsychotics have been associated with QT prolongation. Many common medications can interact with antipsychotics, increasing the risk of cardiac arrhythmias and sudden death. Drug interactions can also lead to increased adverse effects, increased or decreased drug levels, toxicity, or treatment failure. Physicians should carefully consider the risks and benefits of second-generation antipsychotic medications, and patient care should be coordinated between primary care physicians and mental health professionals to prevent serious adverse effects.
ABSTRACT: Acute pericarditis has many potential etiologies and typically presents as a sharp central chest pain that worsens with recumbency and is relieved by leaning forward. The pathognomonic physical finding of acute pericarditis is the pericardial friction rub, which is usually auscultated along the lower left sternal border. The electrocardiogram (ECG) is a useful, simple tool that may aid in the diagnosis of acute pericarditis. Typical ECG findings include diffuse concave-upward ST-segment elevation and, occasionally, PR-segment depression. ECG changes of both acute myocardial infarction and early repolarization can appear similar to ECG changes of acute pericarditis. However, these conditions can usually be excluded by an accurate history, physical examination and recognition of a few key features on the ECG.
ABSTRACT: Electronic fetal heart rate monitoring is commonly used to assess fetal well-being during labor. Although detection of fetal compromise is one benefit of fetal monitoring, there are also risks, including false-positive tests that may result in unnecessary surgical intervention. Since variable and inconsistent interpretation of fetal heart rate tracings may affect management, a systematic approach to interpreting the patterns is important. The fetal heart rate undergoes constant and minute adjustments in response to the fetal environment and stimuli. Fetal heart rate patterns are classified as reassuring, nonreassuring or ominous. Nonreassuring patterns such as fetal tachycardia, bradycardia and late decelerations with good short-term variability require intervention to rule out fetal acidosis. Ominous patterns require emergency intrauterine fetal resuscitation and immediate delivery. Differentiating between a reassuring and nonreassuring fetal heart rate pattern is the essence of accurate interpretation, which is essential to guide appropriate triage decisions.
ABSTRACT: The principal cause of right ventricular infarction is atherosclerotic proximal occlusion of the right coronary artery. Proximal occlusion of this artery leads to electrocardiographically identifiable right-heart ischemia and an increased risk of death in the presence of acute inferior infarction. Clinical recognition begins with the ventricular electrocardiographic manifestations: inferior left ventricular ischemia (ST segment elevation in leads II, III and aVF), with or without accompanying abnormal Q waves and right ventricular ischemia (ST segment elevation in right chest leads V3R through V6R and ST segment depression in anterior leads V2 through V4). Associated findings may include atrial infarction (PR segment displacement, elevation or depression in leads II, III and aVF), symptomatic sinus bradycardia, atrioventricular node block and atrial fibrillation. Hemodynamic effects of right ventricular dysfunction may include failure of the right ventricle to pump sufficient blood through the pulmonary circuit to the left ventricle, with consequent systemic hypotension. Management is directed toward recognition of right ventricular infarction, reperfusion, volume loading, rate and rhythm control, and inotropic support.
ABSTRACT: Mitral valve prolapse is a pathologic anatomic and physiologic abnormality of the mitral valve apparatus affecting mitral leaflet motion. "Mitral valve prolapse syndrome" is a term often used to describe a constellation of mitral valve prolapse and associated symptoms or other physical abnormalities such as autonomic dysfunction, palpitations and pectus excavatum. The importance of recognizing that mitral valve prolapse may occur as an isolated disorder or with other coincident findings has led to the use of both terms. Mitral valve prolapse syndrome, which occurs in 3 to 6 percent of Americans, is caused by a systolic billowing of one or both mitral leaflets into the left atrium, with or without mitral regurgitation. It is often discovered during routine cardiac auscultation or when echocardiography is performed for another reason. Most patients with mitral valve prolapse are asymptomatic. Those who have symptoms commonly report chest discomfort, anxiety, fatigue and dyspnea, but whether these are actually due to mitral valve prolapse is not certain. The principal physical finding is a midsystolic click, which frequently is followed by a late systolic murmur. Although echocardiography is the most useful mode for identifying mitral valve prolapse, it is not recommended as a screening tool for mitral valve prolapse in patients who have no systolic click or murmur on careful auscultation. Mitral valve prolapse has a benign prognosis and a complication rate of 2 percent per year. The progression of mitral regurgitation may cause dilation of the left-sided heart chambers. Infective endocarditis is a potential complication. Patients with mitral valve prolapse syndrome who have murmurs and/or thickened redundant leaflets seen on echocardiography should receive antibiotic prophylaxis against endocarditis.
Listening for Signals - Close-ups
Heparins for Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction - Cochrane for Clinicians
Costochondritis: Diagnosis and Treatment - Article
ABSTRACT: Costochondritis, an inflammation of costochondral junctions of ribs or chondrosternal joints of the anterior chest wall, is a common condition seen in patients presenting to the physician's office and emergency department. Palpation of the affected chondrosternal joints of the chest wall elicits tenderness. Although costochondritis is usually self-limited and benign, it should be distinguished from other, more serious causes of chest pain. Coronary artery disease is present in 3 to 6 percent of adult patients with chest pain and chest wall tenderness to palpation. History and physical examination of the chest that document reproducible pain by palpation over the costal cartilages are usually all that is needed to make the diagnosis in children, adolescents, and young adults. Patients older than 35 years, those with a history or risk of coronary artery disease, and any patient with cardiopulmonary symptoms should have an electrocardiograph and possibly a chest radiograph. Consider further testing to rule out cardiac causes if clinically indicated by age or cardiac risk status. Clinical trials of treatment are lacking. Traditional practice is to treat with acetaminophen or anti-inflammatory medications where safe and appropriate, advise patients to avoid activities that produce chest muscle overuse, and provide reassurance.