Donald D. Tresch

Nonatheromatous Ischemic Heart Disease following Withdrawal from Chronic Industrial Nitroglycerin Exposure

This report describes the clinical, angiographic, and hemodynamic findings in nine patients who manifested nonatheromatous ischemic heart disease induced by chronic industrial exposure to nitroglycerin and subsequent withdrawal. They represent nearly 5% incidence in the group of 200 workers with similar exposure. One patient died suddenly, and the disease was commonly without premonitory symptoms. Of the eight survivors, five were studied and none showed evidence of significant organic obstructive disease. However, in one studied during the withdrawal state, coronary and digital arteriospasm was demonstrated, and was readily reversed by nitroglycerin. Survivors exhibited exercise symptomatology and hemodynamic impairment similar to other patients with myocardial dysfunction from ischemic heart disease. Complete left bundle-branch block with late sudden death occurred in one, and chronic recurrent atrial fibrillation is present in a second.An attractive hypothesis suggests that chronic vasodilatation evokes homeostatic vasoconstriction, the latter persisting during the withdrawal period with cardiac ischemia. A more detailed study of the vasodilator action of organic nitrate and the homeostatic reaction is warranted. In addition, the effect of chronic administration of potent, longacting organic nitrate-based drugs should be examined in the light of this industrial experience.

Heart Failure with Normal Systolic Function: A Common Disorder in Older People

OBJECTIVE: To review the incidence, pathophysiology, significance, diagnosis, and treatment of heart failure with normal systolic function in older patients

Should the elderly be resuscitated following out-of-hospital cardiac arrest?

PURPOSE Elderly and younger patients who were successfully resuscitated and hospitalized following out-of-hospital cardiac arrest were studied to determine if there was a significant difference in hospital course and long-term survival between the two groups. PATIENTS AND METHODS The study consisted of 214 consecutive patients, divided into two age groups: elderly (more than 70 years, n = 112) and younger (less than 70 years, n = 102). Hospital charts and paramedic run data were retrospectively reviewed for each patient and findings were compared between the two age groups. RESULTS Prior to cardiac arrest, 47 of 112 (42 percent) elderly patients had a history of heart failure, compared with 19 of 102 (18 percent) younger patients, and were more commonly taking digitalis (51 percent versus 29 percent) and diuretics (47 percent versus 26 percent). Younger patients, however, more often had an acute myocardial infarction at the time of the cardiac arrest (33 percent versus 16 percent). At the time of cardiac arrest, 83 percent of younger patients demonstrated ventricular fibrillation, compared with 71 percent of the elderly. In contrast, electromechanical dissociation was five times more common in the elderly patients. Although hospital deaths were more common in the elderly (71 percent versus 53 percent), the length of hospitalization and stay in intensive care units were not significantly different between the age groups. The number of neurologic deaths was similar in both age groups, as were residual neurologic impairments. Only five elderly patients and six younger patients required placement in extended-care facilities. Calculated long-term survival curves demonstrated similar survival in both age groups, with approximately 65 percent of hospital survivors alive at 24 months after hospital discharge. CONCLUSION Resuscitation of elderly patients in whom out-of-hospital cardiac arrest occurs is reasonable and appropriate, according to the findings of this study. Even though elderly patients are more likely than younger patients to die during hospitalization, the hospital stay of the elderly is not longer, the elderly do not have more residual neurologic impairments, and survival after hospital discharge is similar to that in younger patients.

Cardiopulmonary Resuscitation in Elderly Patients Hospitalized In The 1990s: A Favorable Outcome

Objective: To compare the clinical characteristics and survival of elderly and younger hospitalized patients who sustain cardiac arrest and receive cardiopulmonary resuscitation (CPR) in the 1990s and to assess predictors of survival.

CONGESTIVE HEART FAILURE IN OLDER PATIENTS: The Clinical Diagnosis of Heart Failure in Older Patients*

OBJECTIVE: To review the differences in presentation and clinical manifestation of heart failure in older and younger patients and to determine if these differences influence the ability to diagnose the disorder clinically. Based on this information, an approach to diagnosing heart failure in older patients is provided.

Spontaneous resolution of a large, cavernous hemangioma of the heart

Cavernous hemangiomas of the heart are rare, benign tumors with an unknown natural history. Most are discrete masses, smaller than 3.5 cm in diameter, and are clinically silent.1 In this report we observed, by echocardiography and computer-assisted tomography, spontaneous regression over a 2-year period of cavernous hemangioma diagnosed by surgical exploration.

Comparison of outcome of paramedic-witnessed cardiac arrest in patients younger and older than 70 years

To obtain further information concerning differences in the mechanism of out-of-hospital cardiac arrest between elderly and younger patients, 381 consecutive patients who experienced out-of-hospital cardiac arrest, and whose arrest was witnessed by paramedics, were studied. In 91% of cases the arrest occurred at the time the patients cardiac rhythm was monitored. Patients were divided into 2 age groups: elderly patients were greater than 70 years (187) and younger patients were less than 70 years (194). Elderly patients more commonly had a past history of heart failure (25 vs 10%, p less than 0.003) and were more commonly taking digoxin (40 vs 20%, p less than 0.005) and diuretics (35 vs 25%, p less than 0.004). Before the cardiac arrest, elderly patients were more likely to be complaining of dyspnea (53 vs 40%, p less than 0.009), whereas younger patients were more likely to complain of chest pain (27 vs 13%, p less than 0.001). Forty-two percent of younger patients demonstrated ventricular fibrillation as the initial out-of-hospital rhythm associated with the arrest, compared to only 22% of elderly patients (p less than 0.001). Besides patient age, initial cardiac rhythm varied according to the patients complaint preceding the arrest. Sixty-eight percent of patients with chest pain demonstrated ventricular fibrillation, whereas only 21% of patients with dyspnea demonstrated ventricular fibrillation. Elderly patients could be as successfully resuscitated as younger patients; however, 24% of younger patients survived, compared to only 10% of elderly patients (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of outcome of resuscitation of out-of-hospital cardiac arrest in persons younger and older than 70 years of age

Abstract Even though sudden death increases with age,1,2 the problem of out-of-hospital cardiac arrest has not been studied in the elderly. In an attempt to determine the effect of age on resuscitation following out-of-hospital cardiac arrest, we studied consecutive victims of out-of-hospital cardiac arrest who received resuscitation by paramedics. Specific out-of-hospital rhythms were analyzed and success of resuscitation and survival were determined according to the victims age and rhythm.

An effective prehospital emergency system.

An Emergency Medical Services (EMS) system with the capabilities of rapid response, patient extrication, basic life support, advanced life support, radio communication, and transportation provides appropriate care for a wide spectrum of injured and acutely ill patients. The validity of the selective dual response system in demonstrated by: 1) rapid provision of basic life support, 2) appropriate availability of advanced life support, 3) conservation of educational and fiscal resources, and 4) the enchancement of knowledge and manipulative skill expertise of relatively few, but busy, EMT-paramedics who are provided close medical supervision and support.

Use of Oral Anticoagulants in Older Patients

Recently published American and British guidelines have comprehensively reviewed the indications for long term anticoagulation. The best evidence currently available supports the use of long term oral anticoagulants in patients with nonvalvular atrial fibrillation (NVAF), venous thromboembolic disease, ischaemic heart disease, mural thrombi, and mechanical heart valves. Selected patients with valvular heart disease, cerebral vascular disease, and peripheral arterial disease may also benefit from the use of these drugs.When no specific contraindications are present, elderly patients with either paroxysmal or persistent NVAF should be considered candidates for treatment with anticoagulants. Pooled analyses of the results from 9 randomised trials demonstrate that warfarin significantly reduces the risk of ischaemic stroke in patients with NVAF, particularly those in a ‘high risk’ category defined by the presence of additional clinical or echocardiographic risk factors. Long term anticoagulation does not appear to be justified in patients with NVAF considered to be at ‘low risk’ for stroke.Because the prevalence of NVAF and most other cardiovascular conditions increases with advancing age, many elderly patients will be candidates for thromboprophylaxis. The potential benefit of long term anticoagulation must be carefully weighed against the risk of serious haemorrhage in such patients. Bleeding complications with anticoagulant drugs appear to occur more frequently in older patients than in younger individuals. Advanced age (>75 years), intensity of anticoagulation [International Normalised Ratio (INR) >4.0], history of cerebral vascular disease (recent or remote), and concomitant use of drugs that interfere with haemostasis [aspirin (acetylsalicyclic acid) or nonsteroidal anti-inflammatory drugs] are among the most important variables in determining an individual’s risk for major bleeding with anticoagulants.Older patients often display increased sensitivity to the effects of warfarin, both in the early induction phase and during the long term maintenance phase of therapy. Conditions such as congestive heart failure, malignancy, malnutrition, diarrhoea and unsuspected vitamin K deficiency, enhance the prothrombin time response.The decision to interrupt anticoagulant therapy before elective surgery in elderly patients should evaluate the thrombotic risk of such a manoeuvre versus the risk of bleeding if anticoagulants are continued. In non-surgical patients, excessively elevated INRs without associated haemorrhage can usually be managed by simply witholding one or several doses of warfarin. If more rapid reversal is needed, small doses of phytomenadione (vitamin K1) can be administered safely without overcorrection or the development of vitamin K-induced warfarin resistance.