Jaffar Ali Raza

Use of cardiovascular medications in the elderly

Cardiovascular disease is the leading cause of death in patients aged 65 and above. Although elderly persons represent only 12.4% of the US population, they account for about a third of drug expenditures. However the appropriate use of cardiovascular medications in these patients has been shown to reduce the rate of cardiovascular morbidity and mortality. The normal aging and the disease process in the elderly result in significant changes at the structural and molecular level in the elderly. The changes that take place in the autonomic nervous system, the kidneys, and the liver in the elderly modify the metabolism and clinical effects of most medications. Elderly patients are also susceptible to side effects and adverse drug reactions. Physicians should have a clear understanding of the normal aging processes, the abnormal changes due to disease process and the changes in the pharmacology of drugs in the elderly to deliver proper care to the elderly patient.

Aortic atheromas: current concepts and controversies-a review of the literature.

The frequent use of transesophageal echocardiogram (TEE) has led to the increased recognition of aortic atheromas. Retrospective and prospective follow‐up studies have reported an association between aortic atheromas and stroke in the high‐risk patient population, with complex plaques being more likely to embolize than simple plaques. However, TEE‐based studies in the low‐risk cohorts have failed to show a similar association. There is growing body of evidence suggesting that aortic atheroma is a marker of generalized atherosclerosis. Although magnetic resonance (MR) imaging and computed tomography (CT) scan are emerging as a powerful noninvasive tool for characterization of aortic atheromas, TEE is the imaging modality of choice. Currently, treatment of aortic atheromas is not well defined, and mixed outcomes have been reported for anticoagulation therapy with warfarin. Statins appear promising based on their plaque stabilization properties. However, there are no randomized control trials to establish the role of both anticoagulation and statins in patients with aortic atheromas, and are warranted in the future.

Pharmacological stress agents for evaluation of ischemic heart disease

Ischemic heart disease is the leading cause of death in the developed countries for those older than 65 years of age. In patients suspected to have coronary artery disease a stress test should be performed to identify the vulnerability of the myocardium to ischemia. As a rule of thumb, the evaluation of coronary artery disease is best done by exercise stress test. In patients who are not able to exercise adequately, pharmacological stress agents are used. The commonly used agents are the coronary vasodilators, adenosine and dipyridamole and the catecholamines, dobutamine and arbutamine. These agents are combined with imaging techniques to increase the sensitivity and specificity of the test. These agents have been widely used and have an excellent safety profile. Another advantage in using pharmacological stress agents is that they do not affect the image quality, especially with echocardiography and magnetic resonance imaging. Ongoing developments hold promise for safer and more reliable pharmacological stress agents in the future.

Cell transplantation for treatment of left-ventricular dysfunction due to ischemic heart failure: from bench to bedside

Cell transplantation is an innovative technology that involves the implantation of a variety of myogenic and angiogenic cell types. The transplanted cells proliferate and augment left ventricular performance and therein ameliorate the heart failure symptoms. The concept of cell transplantation has followed the footsteps of angiogenesis starting as bench side research. The latter half of the decade saw the transformation of this potential mechanism to a promising therapy for ischemic heart failure. More than 150 patients have been treated with cellular transplantation worldwide. This novel application has the potential to revolultionalize alternative therapeutic approaches to management of heart failure.

Anti-Arrhythmic Drugs: Pharmacokinetics and Pharmacodynamics

The goals of antiarrhythmic drug therapy are to control heart rate, abolish tachyarrhythmias, suppress ectopic beats, and to restore and maintain normal sinus rhythm. The selection of appropriate agents is a match between the common antiarrhythmic drugs, the condition and age of the patient, the urgency of treatment, the potential long-term side effects, and especially the drug’s proven efficacy on the arrhythmia in question [1]. This chapter will discuss the pharmacokinetics and pharmacodynamics of the commonly utilized and marketed antiarrhythmic drugs.

Myocardial Perfusion Scintigraphy in the Assessment of Post-Revascularization – Current Status and Limitations

Myocardial perfusion imaging (MPI) is widely utilized in the non-invasive diagnosis and management of coronary artery disease (CAD). Radionuclide MPI has been well studied in the evaluation, risk stratification and identification of patients with CAD who will benefit from revascularization. Myocardial revascularization using percutaneous coronary interventions (PCI) and coronary artery bypass graft (CABG) has become a mainstay in the treatment of patients with CAD. The idea of performing a functional study after revascularization is to identify the areas that are not revascularized or to look for restenosis and progression of native vessel disease or disease in the grafts.

Echocardiography and Contrast Echocardiography

In 1953, Dr. Helmut Hertz of Sweden together with Dr. Inge Edler began to use a commercial ultrasonoscope to examine the heart, thus starting the era of clinical echocardiography [1].

Clinical Cardiac Electrophysiology – An Overview

Clinical cardiac electrophysiology is a subspecialty of cardiology dealing with the evaluation and management of patients with complex rhythm or conduction abnormalities. In the last four decades, clinical cardiac electrophysiology has evolved into an established discipline credited with improving and saving hundreds of thousands of lives. We briefly review the basic electrophysiologic principles, anatomy of the electric system of the heart, mechanism of arrhythmias, genetical predisposition to arrhythmias, types of arrhythmias, diagnostic electrophysiologic studies, and pharmacologic and device therapies available for the treatment of different types of arrhythmias.

Cardiovascular Medications: Pharmacokinetics and Pharmacodynamics

Cardiovascular diseases (CVD) have reached epidemic proportions in developed countries, and are the leading cause of morbidity and mortality. An estimated 16.7 million – or 29.2% of total global deaths – result from the various forms of CVD, many of which are preventable by healthy diet, regular physical activity, and smoking cessation [1]. CVD is no longer the disease of the developed world: some 80% of all CVD deaths worldwide took place in developing, low and middle-income countries and these countries also account for 86% of the global CVD disease burden. By 2010, CVD will be the leading cause of death in developing countries. The rise in CVD reflects a significant change in diet habits, physical activity levels, and tobacco consumption worldwide as a result of industrialization, urbanization, economic development and food market globalization. To deal with this changing situation, an extraordinary array of new cardiovascular therapies continues to become available. These drugs and therapies are efficacious and are better tolerated than their predecessors, not only in the management but also in prevention of CVD. This results in ever more difficulty for the practitioners of medicine in understanding the mechanism of action of these medications and also in deciding the proper medication for their patients. This chapter is a concise presentation of the pharmacology of cardiovascular medications.