Warfarin for stroke prevention in octogenarians with atrial fibrillation.

The authors examined warfarin use in elderly patients with atrial fibrillation. Medical records were abstracted from a random sample of Medicare beneficiaries with atrial fibrillation who were discharged from Kansas hospitals. Data were analyzed for warfarin and aspirin use and risk factors for stroke or bleeding in patients 65-79 years of age or 80 years and older. Stroke risk factors other than age and atrial fibrillation were seen in 98% of 142 patients less than 80 years of age and 100% of 141 octogenarians. Warfarin use was similar in the younger and older age groups (50% vs. 45%, respectively; p = ns) and was not associated with the number of stroke or bleeding risk factors. Compared to patients less than 80 years of age, octogenarians were less likely to receive aspirin (38% vs. 27%, respectively; p < 0.05). Anticoagulation rates for high-risk patients with atrial fibrillation were low and poorly explained by stroke or bleeding risks.

Aggressive diuresis for severe heart failure in the elderly.

STUDY OBJECTIVE: To determine the efficacy, safety, and economic benefit of continuous IV infusion of furosemide as a treatment modality for elderly patients with class IV heart failure. DESIGN: Prospective trial of consecutively admitted elderly patients > 65 years old with class IV heart failure. SETTING: A single cardiovascular service in a university medical center. PATIENTS: Seventeen male and female patients > 65 years old consecutively admitted to a cardiovascular service. RESULTS: High-dose, continuous IV infusion of furosemide was successful in providing a 9- to 20-L diuresis in an average of 3.5 days without causing clinical complications or aberrations in blood chemistry. The length of stay was 2.3 days shorter than a contemporary group of class III and class IV elderly patients with heart failure managed on other medical services. The Medicare reimbursement for heart failure was $6,047. Patients receiving IV bolus diuretic therapy incurred billing charges of $10,193, or a loss of $4,146 per patient to the hospital. Patients receiving diuretic infusion therapy incurred billing charges of $4,944. This was a difference of $5,249 per patient treated by continuous IV infusion compared to bolus therapy and a profit per Medicare patient of $1,103. Therefore, a $4,146 billing loss was converted to $1,103 profit. CONCLUSION: IV furosemide infusion therapy for class IV heart failure in the elderly is a safe, effective, and economic mode of therapy.

Thrombolism with atrial flutter.

These data provide convincing evidence that patients with atrial flutter have a significant thromboembolic risk. Their anticoagulation should be managed in the same manner as patients with atrial fibrillation.

Severe musculoskeletal symptoms during continuous infusion of bumetanide.

BACKGROUND: The continuous infusion of the loop diuretic, bumetanide, has been shown to be effective in the treatment of severe refractory edema. Musculoskeletal symptoms have been reported with bumetanide following both oral and intermittent i.v. bolus therapy. It has been suggested that these adverse effects do not occur with continuous infusion. We describe, however, a series of patients with heart failure who developed severe disabling musculoskeletal symptoms during the continuous infusion of humetanide. OBJECTIVE: To evaluate the characteristics of bumetanide-induced musculoskeletal symptoms during continuous i.v. infusion in patients with severe heart failure. METHODS: Heart failure patients receiving continuous infusions of bumetanide were monitored for the development of musculoskeletal symptoms. For patients who experienced the adverse reaction, data were collected on demographics, medical diagnoses, concurrent medications, the diuretic regimen, symptoms, time course of the reaction, laboratory findings, alternative therapy, and outcomes. RESULTS: Of 34 patients who received continuous infusions of bumetanide, eight patients experienced a total of 11 episodes of severe musculoskeletal symptoms. All patients had severe congestive heart failure and refractory edema. The reaction was most severe at infusion rates of approximately 2 mg/h and was not associated with any specific laboratory abnormality. The symptoms resolved completely after discontinuing the bumetanide therapy. In two of the patients, the adverse reaction was precipitated again during rechallenge with the bumetanide infusion. Patients who were given an equivalent or higher dose of a continuous furosemide infusion, diuresed without experiencing musculoskeletal symptoms. CONCLUSIONS: The continuous i.v. infusion of the loop diuretic, bumetanide, may result in severe, disabling musculoskeletal symptoms. The reaction appears to be dose related, without specific risk factors, and is reversible on discontinuation of the infusion. Patients who experience this reaction may be successfully diuresed with equivalent doses of a furosemide infusion.

Postinfarction ventricular aneurysms.

Ventricular aneurysms are circumscribed, thin-walled fibrous, noncontractile outpouchings of the ventricle. The majority are apically located, true aneurysms of the left ventricle (LV) that occur as a consequence of transmural myocardial infarction (MI). The precursor of aneurysm formation appears to be infarct expansion early after acute MI and occurrence generally relates to infarct size. The presence of underlying hypertension and the use of steroids and nonsteroidal antiinflammatory agents may promote aneurysm formation. The clinical sequelae include congestive heart failure (CHF), thromboembolism, angina pectoris, and ventricular tachyarrhythmias. Late rupture is a particular complication of false aneurysms in which the pericardium is the aneurysm wall. The diagnosis may be suspected by the clinical finding of a diffuse, pansystolic apical thrust, persistent ST-segment elevation on the electrocardiogram, and distortion of the cardiac silhouette on chest x-ray. This can be confirmed using echocardiography, radionuclide ventriculography, and cardiac catheterization. The latter has the additional advantage of being able to delineate the coronary anatomy. Management involves prevention, specific therapy for the various clinical manifestations, and surgery. Therapeutic interventions with thrombolytic agents, aspirin, heparin, and beta blockers that are applied early in the evolution of an MI may limit infarction size, thereby reducing the tendency toward infarct expansion and aneurysm formation. Patients with mild CHF can usually be controlled with the standard combination of angiotensin-converting enzyme inhibitors, diuretics, and digoxin. Thromboembolism is best prevented by anticoagulation with warfarin for at least 3 months after the acute MI. The choice of pharmacotherapy for ventricular tachyarrhythmias should be guided by electrophysiologic studies. The treatment of patients with angina pectoris utilizes conventional therapeutic modalities.(ABSTRACT TRUNCATED AT 250 WORDS)

'Vampire syndrome': serum protein and lipid abnormalities related to frequent sale of plasma.

The sale of plasma for profit has become a common occurrence. In the United States, a healthy individual can donate as frequently as six times per month and up to 60 L of plasma per year. Although plasma donors are generally healthy, intervening conditions can increase the catabolism or decrease the synthesis of certain serum constituents and thereby produce a confusing clinical picture. In 1 month, we encountered two patients who presented with hypoalbuminemia and hypocholesterolemia for which there was no obvious cause except a history of frequent plasma sales.

Low-intensity anticoagulation in mechanical cardiac prosthetic valves.

Retrospectively, we reviewed the charts of 101 patients at the University of Kansas Medical Center who received low-intensity anticoagulation for mechanical prosthetic valves implanted over a 17-yr period. The mean duration of follow-up was 4.6 yr, and the total duration of follow-up was 466.5 patient-yr. The patients' records were evaluated for evidence of hemorrhagic or thromboembolic complications. A prothrombin time ratio of 1.3 to 1.5 times control was considered to be low-intensity anticoagulation. There were three thromboembolic events or 2.9/100 patient-yr of follow-up at a prothrombin time ratio of less than 1.3, four thromboembolic events or 2.5/100 patient-yr of follow-up at 1.3 to 1.5 times control, four thromboembolic events or 2.2/100 patient-yr of follow-up at 1.6 to 2.0 times control, and no thromboembolic events at prothrombin time ratios greater than 2.0 times control. Hemorrhagic events occurred in three patients at a prothrombin time ratio of less than 1.3 times control or 2.8/100 patient-yr of follow-up, in six patients at 1.3 to 1.5 times control or 3.8/100 patient-yr of follow-up, in ten patients at 1.6 to 2.0 times control or 5.5/100 patient-yr of followup, and in two patients at 2.1 to 2.5 times control or 12.2/100 patient-yr of follow-up. The rate of hemorrhagic events at 2.5 times control was 470/100 patient-yr follow-up. While not providing definitive proof, we believe that our retrospective study provides supportive evidence for the use of low-intensity anticoagulation in patients with mechanical cardiac prostheses.

Phenytoin hypersensitivity syndrome: a case report.

We report a life-threatening case of phenytoin hypersensitivity syndrome, a rare reaction primarily characterized by fever, skin eruptions, lymphadenopathy, eosinophilia, and hepatotoxicity. The reaction developed in a 27-year-old black man with surgically corrected tetralogy of Fallot who was treated with phenytoin for one month for exercise-induced sustained ventricular tachycardia. Phenytoin therapy was discontinued and the patient was treated with intravenous methylprednisolone; the therapy was later converted to oral prednisone. Clinical improvement was noted five days after admission and the patient was discharged on hospital day 14. This adverse reaction usually develops within six weeks of starting phenytoin therapy and may be fatal in up to 40 percent of the patients who develop hepatotoxicity. Early recognition of this relatively rare reaction is essential to prevent serious and potentially fatal complications.

Primary pulmonary hypertension in adults.

Primary pulmonary hypertension is an enigmatic disease found predominantly in young women, but it also affects a significant number of middle-aged and elderly males and females. Its onset, characterized by progressively worsening dyspnea, fatigue, and chest pain, is insidious. Three distinct histopathologic subtypes have been identified, and the natural history of the disease process has been well-defined. Pharmacologic treatment options have, in general, been disappointing, and it appears that heart-lung transplantation will be applied only to a small minority of young patients with primary pulmonary hypertension in the near future. We review the histopathology, evaluation, treatment, and prognosis of primary pulmonary hypertension.

The significance of eosinophils in mild and moderate acute cardiac allograft rejection.

The presence of eosinophils has previously been associated with severe acute cardiac allograft rejection. This appears to be a relatively uncommon finding, judging from our experience and the paucity of information appearing in literature. We report three cases where a prominent infiltrate of eosinophils was noted on endomyocardial biopsy following cardiac transplantation. There was no evidence of severe acute rejection in any of these three patients, and one patient had only mild acute rejection without even focal myocardial necrosis. An infiltrate, which includes eosinophils, does not appear to be restricted to severe acute cardiac allograft rejection. Therefore, when eosinophils are noted in endomyocardial biopsy specimens, decisions to revise the immunosuppressive regimen of cardiac transplant recipients should continue to be based upon established conventional histologic criteria.

Chest pain.

The accurate diagnosis of chest pain is often difficult. We review the differential diagnosis of chest pain and the diagnostic studies used in the evaluation of chest pain syndromes. Myocardial ischemia, aortic dissection, pulmonary embolism, pericarditis, and gastroenterologic sources of chest pain are the most common. The chest X-ray, electrocardiogram, echocardiogram, heart catheterization studies, and esophageal studies are helpful diagnostically.