Hancock Ew

Timing of valve replacement for aortic stenosis

Timing of valve replacement for aortic stenosis ISSN: 1524-4539 Copyright

Effects of Amyl Nitrite in Aortic Valvular and Muscular Subaortic Stenosis

The effects of amyl nitrite inhalation were observed in 12 patients with aortic valve stenosis and five patients with muscular subaortic stenosis during left heart catheterization. In aortic valve stenosis the left ventricular systolic pressure always fell, although less than the brachial arterial pressure, and the transaortic systolic pressure gradient rose by an average of 25% due to the increase in left ventricular ejection rate. In muscular subaortic stenosis, the left ventricular pressure always remained the same or rose despite a marked fall in brachial arterial pressure, and the average increase in transaortic systolic pressure gradient was more than fourfold. This effect was associated with a significant increase in the degree of outflow tract obstruction. The increase in outflow tract obstruction is thought to be due to a decrease in left ventricular volume, causing the hypertrophied walls of the left ventricle to become more closely apposed.We believe that inhalation of amyl nitrite is superior to infusion of isoproterenol as a provocative test for muscular subaortic stenosis during cardiac catheterization and is probably the most potent stimulus available for this purpose.

Near-syncope and abnormal T waves in a young woman.

of Medicine, Stanford, Calif. A 30-year-old woman was seen in the emergency department for chest pain and several near-syncopal episodes over the past two days. Her symptoms had begun suddenly, with diffuse nonpleuritic discomfort in the anterior chest, shortness of breath, and sweating. The chest discomfort was intermittent and not progressive, but she had had several episodes of nearsyncope while walking. The patient had been diagnosed more than 10 years earlier as having hemoglobin SC disease. She had chronic low-grade anemia and occasional crisis episodes that mainly involved pain in the lower extremities. Her medications included gabapentin, hydroxyurea, and folic acid. She appeared to be fatigued and was dyspneic on slight exertion. The temperature was 37.4, pulse 74 and regular, respirations 18, blood pressure 115/77, and arterial oxygen saturation 96o/o while breathing room air. There were no abnormal physical findings. The chest radiograph showed mild elevation of both diaphragms and a mild, ill-defined increase in density in the left lower lobe. The white blood cell count was 7,000 with a normal differential. The hemoglobin was 10.0, the hematocrit 30.2, and the platelet count 390,000. The ECG is shown. An ECG recorded 18 months earlier had been normal.

A criterion-referenced examination in cardiovascular disease †

Summary. This study described criterion‐referenced tests of electrocardiograph reading skill and basic knowledge in cardiology, assessed their dependability and validity, and explored their impact on overall certification rates. Data indicated that the standard‐setting processes and the two criterion‐referenced tests produced dependable results both separately and together. Scores of each had the expected relationships with quality of residency training and experience with the examination. Moreover, these sections of the examination identified a small subset of examinees who failed the criterion‐referenced sections but passed the norm‐referenced examinations. Taken as a whole these results replicate the findings of an earlier study in terms of a criterion‐referenced test of electrocardiograph reading skill and extended them to a criterion‐referenced test of basic knowledge in cardiology.

Anterior and Inferior Injury

A 74-year-old man experienced sudden severe chest pain while seated at his desk. The pain was sub sternal, and associated with weakness, sweating, and fullness in the epigastrium. He drove himself to the emergency department. On examination he appeared weak, pale, and sweaty, with systolic blood pressure 70 mm Hg by palpation: pulse. 66 bpm: respirations, 16 per min; temperature, 36.8° C: and oxygen saturation 92% by pulse oximetry. The jugular venous pressure was moderately elevated, and there were crackles at both lung bases. The heart sounds were nearly inaudible.

Rapid evolution of acute myocardial infarction.

Dr. Hancock is Professor of (Cardiovascular) Medicine Emeritus, Stanford University School of Medicine, Stanford, Calif. A 79-year-old man presented to the emergency department in the evening complaining of substernal pressure discomfort. The discomfort had begun an hour earlier after he had eaten a light dinner. Additional symptoms included mild dyspnea, lightheadedness, and sweating. Several similar episodes had occurred during the past month; however, these episodes had lasted only one to two minutes and the ECGs had been normal. The patient appeared to be in mild distress, despite sublingual administration of two nitroglycerine tablets. Blood pressure was 145/87 mm Hg; pulse, 55/min and regular; temperature, 37.3°C; respirations, 16/min; and oxygen saturation, 96% while breathing room air. There were no notable abnormalities on the physical examination. The ECG is shown.

Pulmonary Edema with Wide-Complex Tachycardia

A 58-year-old woman came to the emergency department with severe shortness of breath. Her symptoms had developed late in the evening after several days of Increasing cough and dyspnea on exertion. There was no chest pain or palpitation. She had had hypertension for the past 10 years, treated intermittently with metoprolol and hydrochlorothiazide. A month before this presentation she had discontinued those medications because her supply ran out.She was an obese woman in moderate respiratory distress. Blood pressure was 190/120 mm Hg, pulse was 140 beats per minute and regular, respirations were 32 per minute, temperature was 37.1°C, and arterial oxygen saturation was 96%. Her skin was cool and moist. The arterial pulses were small in volume but symmetrical. Crackles and coarse rhonchi were heard throughout the chest. Cardiac examination showed rapid regular rhythm with three sounds per cycle, probably reflecting the presence of an S4 or a summation gallop. No variability in heart sounds or arterial pulse v...

LONG QT INTERVAL IN A YOUNG WOMAN WITH SEVERE WEAKNESS

A 19-year-old woman was admitted to the hospital after she called emergency medical services because of severe weakness. The patient had been under psychiatric care for several years for an eating disorder, but she had considered herself to be in good health physically. Her medications included 20 mg of cisapride three times a day, terbinafine cream daily, 20 mg of fluoxetine daily, and calcium and potassium supplements daily.The patient was thin and in no acute distress, except for severe generalized muscular weakness. Her pulse was 60 beats per minute and regular; blood pressure, 95/65 mm Hg; respirations, 16 per minute; and temperature, 36.8°C. Her general and neurologic examinations were unremarkable except for generalized muscular weakness.The ECG recorded in the emergency department is shown.

Hypothermia, Slow Pulse, and an Unusual QRS Complex

A 63-year-old man was brought to the emergency department by paramedics after being found in an alley in back of a drinking establishment on an unusually cold winter night. The police recognized the patient as a homeless person who had been frequently arrested for drunkenness.The patient was markedly obtunded; pulse was 38 beats per minute and regular. Blood pressure was 60/40 mm Hg, respirations were eight per minute, and rectal temperature was 29°C (84.2°F). He was flaccid and areflexic but moved all extremities in response to deep pain. Findings on general physical examination were otherwise unremarkable.The ECG is shown.

TACHYCARDIA IN A 60-YEAR-OLD MAN

A 60-year-old man was seen for evaluation of intermittent palpitation. For the preceding three weeks he had noted periods of rapid heartbeat that occurred every few days and lasted most of the day. He had noticed it more often when he was at rest than during activity. He had not had chest pain, dyspnea, or other symptoms.There was no history of heart disease or cardiac symptoms. However, during the preceding Ave years his blood pressure had ranged from 150 to 160 mm Hg systolic and from 85 to 90 mm Hg diastolic, and his total serum cholesterol had ranged from 215 to 235 mg/dL. He was not a smoker.The patient was slightly obese and appeared to be healthy and in no acute distress. His pulse was 147 beats per minute and regular, blood pressure was 165/95 mm Hg, respirations were 18 per minute, and temperature was 37.1°C. His skin was warm and dry. The thyroid was impalpable. The jugular venous pressure was normal, the lungs were clear to percussion and auscultation, and the cardiac examination was unremarkab...