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Treatment of Menorrhagia - Article
ABSTRACT: Menorrhagia is defined as excessive uterine bleeding occurring at regular intervals or prolonged uterine bleeding lasting more than seven days. The classic definition of menorrhagia (i.e., greater than 80 mL of blood loss per cycle) is rarely used clinically. Women describe the loss or reduction of daily activities as more important than the actual volume of bleeding. Routine testing of all women with menorrhagia for inherited coagulation disorders is unnecessary. Saline infusion sonohysteroscopy detects intracavitary abnormalities such as endometrial polyps or uterine leiomyoma and is less expensive and invasive than hysteroscopy. Endometrial biopsy is effective for diagnosing precancerous lesions and adenocarcinoma but not for intracavitary lesions. Except for continuous progestin, medical therapies are limited. The levonorgestrel-releasing intrauterine device is an effective therapy for women who want to preserve fertility and avoid surgery. Surgical therapies include endometrial ablation methods that preserve the uterus; and hysterectomy, which results in high satisfaction rates but with potential surgical morbidity. Overall, hysterectomy and endometrial ablation result in the greatest satisfaction rates if future childbearing is not desired. Treatment of menorrhagia results in substantial improvement in quality of life.
ABSTRACT: The American College of Cardiology and American Heart Association, in collaboration with the Canadian Cardiovascular Society, have issued an update of the 2004 guideline for the management of patients with ST-segment elevation myocardial infarction. The American Academy of Family Physicians endorses and accepts this guideline as its policy. Early recognition and prompt initiation of reperfusion therapy remains the cornerstone of management of ST-segment elevation myocardial infarction. Aspirin should be given to symptomatic patients. Beta blockers should be used cautiously in the acute setting because they may increase the risk of cardiogenic shock and death. The combination of clopidogrel and aspirin is indicated in patients who have had ST-segment elevation myocardial infarction. A stepped care approach to analgesia for musculoskeletal pain in patients with coronary heart disease is provided. Cyclooxygenase inhibitors and nonsteroidal anti-inflammatory drugs increase mortality risk and should be avoided. Primary prevention is important to reduce the burden of heart disease. Secondary prevention interventions are critically important to prevent recurrent events in patients who survive.
ABSTRACT: Supraventricular arrhythmias are relatively common, often persistent, and rarely life-threatening cardiac rhythm disturbances that arise from the sinus node, atrial tissue, or junctional sites between the atria and ventricles. The term "supraventricular arrhythmia" most often is used to refer to supraventricular tachycardias and atrial flutter. The term "supraventricular tachycardia" commonly refers to atrial tachycardia, atrioventricular nodal reentrant tachycardia, and atrioventricular reciprocating tachycardia, an entity that includes Wolff-Parkinson-White syndrome. Atrial fibrillation is a distinct entity classified separately. Depending on the arrhythmia, catheter ablation is a treatment option at initial diagnosis, when symptoms develop, or if medical therapy fails. Catheter ablation of supraventricular tachycardias, atrial flutter, and atrial fibrillation offers patients high effectiveness rates, durable (and often permanent) therapeutic end points, and low complication rates. Catheter ablation effectiveness rates exceed 88 percent for atrioventricular nodal reentrant tachycardia, atrioventricular reciprocating tachycardia, and atrial flutter; are greater than 86 percent for atrial tachycardia; and range from 60 to 80 percent for atrial fibrillation. Complication rates for supraventricular tachycardias and atrial flutter ablation are 0 to 8 percent. The complication rates for atrial fibrillation ablation range from 6 to 10 percent. Complications associated with catheter ablation result from radiation exposure, vascular access (e.g., hematomas, cardiac perforation with tamponade), catheter manipulation (e.g., cardiac perforation with tamponade, thromboembolic events), or ablation energy delivery (e.g., atrioventricular nodal block).
ABSTRACT: The most common types of supraventricular tachycardia are caused by a reentry phenomenon producing accelerated heart rates. Symptoms may include palpitations (pulsation in the neck), chest pain, lightheadedness or dizziness, and dyspnea. It is unusual for supraventricular tachycardia to be caused by structurally abnormal hearts. Diagnosis is often delayed because of the misdiagnosis of anxiety or panic disorder. Patient history is important in uncovering the diagnosis, whereas the physical examination may or may not be helpful, and usually necessitates use of a Holter monitor or an event recorder to capture the arrhythmia and confirm a diagnosis. Treatment consists of short-term or as needed pharmacotherapy using calcium channel or beta blockers when vagal maneuvers fail to halt or slow the rhythm. In those who require long-term pharmacotherapy, atrioventricular nodal blocking agents or class IC or III antiarrhythmics can be used; however, these agents should generally be managed by a cardiologist. Catheter ablation is an option in patients with persistent or recurrent supraventricular tachycardia who are unable to tolerate long-term pharmacologic management. If Wolff-Parkinson-White syndrome is present, expedient referral to a cardiologist is warranted because ablation is a potentially curative option.
ABSTRACT: Procedures performed by an interventional radiology specialist are becoming increasingly important in the management of patients with cancer. Although general interventional radiology procedures such as angiography and angioplasty are used in patients with and without cancer, certain procedures are reserved for the diagnosis and treatment of cancer or cancer-related complications. Interventional radiology procedures include imaging-guided biopsies to obtain samples for cytologic or pathologic testing without affecting adjacent structures. Transjugular liver biopsy is used to diagnose hepatic parenchymal abnormalities without traversing Glisson's capsule. This biopsy procedure is particularly useful in patients with coagulopathies. Because the transjugular liver biopsy obtains random samples, it is not recommended for biopsy of discrete hepatic masses. Fluid collections can also be sampled or drained using interventional radiology techniques. Transcatheter chemoembolization is a procedure that delivers a chemotherapeutic agent to a tumor along with sponge particles that have an ischemic effect on the mass. Tumor ablation, gene therapy and access of central veins for treatment are performed effectively under radiographic guidance. Cancer complications can also be treated with interventional radiology techniques. Examples include pain control procedures, vertebroplasty and drainage of obstructed organs. Interventional radiology techniques typically represent the least invasive definitive diagnostic or therapeutic options available for patients with cancer. They can often be performed at a lower cost and with less associated morbidity than other interventions.
ABSTRACT: Atrial fibrillation is the most common cardiac arrhythmia. It impairs cardiac function and increases the risk of stroke. The incidence of atrial fibrillation increases with age. Key treatment issues include deciding when to restore normal sinus rhythm, when to control rate only, and how to prevent thromboembolism. Rate control is the preferred management option in most patients. Rhythm control is an option for patients in whom rate control cannot be achieved or who have persistent symptoms despite rate control. The current recommendation for strict rate control is a resting heart rate of less than 80 beats per minute. However, one study has shown that more lenient rate control of less than 110 beats per minute while at rest was not inferior to strict rate control in preventing cardiac death, heart failure, stroke, and life-threatening arrhythmias. Anticoagulation therapy is needed with rate control and rhythm control to prevent stroke. Warfarin is superior to aspirin and clopidogrel in preventing stroke despite its narrow therapeutic range and increased risk of bleeding. Tools that predict the risk of stroke (e.g., CHADS2) and the risk of bleeding (e.g., Outpatient Bleeding Risk Index) are helpful in making decisions about anticoagulation therapy. Surgical options for atrial fibrillation include disruption of abnormal conduction pathways in the atria, and obliteration of the left atrial appendage. Catheter ablation is an option for restoring normal sinus rhythm in patients with paroxysmal atrial fibrillation and normal left atrial size. Referral to a cardiologist is warranted in patients who have complex cardiac disease; who are symptomatic on or unable to tolerate pharmacologic rate control; or who may be candidates for ablation or surgical interventions.