1695T he incidence of coronary artery disease (CAD) in women of child-bearing age is low, and acute myocardial infarction (AMI) is uncommon.1,2 Pregnancy, however, has been shown to increase the risk of AMI ≈3-fold compared with the risk in nonpregnant women of similar age. [2][3][4][5] Although previous studies have provided some data related to the incidence of pregnancyassociated MI (PAMI), clinical characteristics, risk factors, and outcome 1,2,4 more information is needed on the mechanisms of AMI, the efficacy and safety of standard therapy, and the applicability of guideline recommendations designed for the general AMI population, to women with PAMI.The aim of this study was therefore to review contemporary data on PAMI in an attempt to provide recommendations for the management of this condition. MethodsA literature search for cases with AMI related to pregnancy was performed using PubMed and Google Scholar. References from these studies were cross-checked to obtain additional studies that may have been missed by the original search.All original articles were obtained online or by interlibrary communication. Articles published in languages other than English were translated by medical translators. A total of 134 cases published in the literature from 2006 to 2011 not included in a previous review 4 were included in this study. In addition, 7 cases presented at the First International Congress on Cardiac Problems in Pregnancy in 2010 (Valencia, Spain) and 9 patients treated or consulted by the authors were also included in the analysis. Recommendations were made on the basis of available clinical information, with the understanding that the cases published in the literature and reviewed by us do not represent all the patients who developed PAMI during the period of the study and that reporting may therefore be incomplete and biased. ResultsOne hundred fifty patients with PAMI were included in the study (Table 1). The age ranged from 17 to 52 years; the mean age was 34±6 years; 75% of the patients were >30 years of age; and 43% were >35 years. Reported risk factors for CAD included smoking in 25% of the patients, dyslipidemia in 20%, hypertension in 15%, and diabetes mellitus and a family history of CAD in 9% each.The type and timing of AMI are shown in Figure 1. Data on the type of AMI were available in 139 of the patients. Of these, 105 (75%) presented with ST-segment-elevation MI (STEMI) and the rest with non-STEMI (NSTEMI). The majority of the patients developed AMI during either the third trimester of pregnancy (STEMI, 25%; NSTEMI, 32%) or the postpartum period (STEMI, 45%; NSTEMI, 55%). The myocardial infarct involved the anterior wall of the left ventricle (LV) in 69% of the patients, the inferior wall in 27%, and the lateral wall in 4%. Table 2 shows the mechanisms of AMI. Coronary angiography was performed in 129 patients and demonstrated coronary dissection (CD) in 56 patients (43%), atherosclerotic disease in 27%, a clot without angiographic evidence for atherosclerotic disease in 22 patients (1...
Anticoagulation with adjusted dose LMWH aimed to achieve guideline-recommended peak levels of anti-Xa for patients with MPHVs is commonly associated with subtherapeutic trough levels. Routine measurement of trough anti-Xa levels is therefore advisable in women with MPHV treated with LMWH during pregnancy to assure adequate level of anticoagulation.
Inadequate training in cancer survivorship represents a barrier to providing adequate cancer follow-up. Inexperience or unawareness of essential survivorship issues could lead to mistakes which affect survivors' health and timely assessment of long-term cancer-associated morbidity. As PCPs will play a key role in the delivery of survivorship care, effective educational opportunities and achievement of competencies in adult cancer survivorship care by primary care trainees are needed.
H eart failure (HF) is a common cardiovascular cause of hospitalizations in the United States and the most frequent reason among patients aged 65 years and older. 1 A recent report by the National Hospital Discharge Survey showed an increase in the number of hospital admissions with a diagnosis of HF from Ϸ1.3 million in 1979 to 3.9 million in 2004, with 30% to 35% of these carrying a primary diagnosis of HF. 2 Recent data from several large registries of HF hospitalizations have demonstrated in-hospital mortality as high as 4% to 7%. 3,4 Contributing to this is a significant incidence of VTE among hospitalized patients with HF. 5 In addition, VTE is associated with thromboembolic complications, which are associated with long-term sequelae including postthrombotic syndromes, venous stasis, venous ulcers, chronic thromboembolic pulmonary hypertension, and pulmonary embolism (PE). 6-8 These conditions are often associated with edema and chronic pain, which can have a significant impact on mobility and quality of life. Recurrent VTE and PE are also common complications reported in as many as 30% of patients. 9 Published information suggests that despite availability of effective therapy and existence of practice guidelines, 10,11 there is a significant underutilization of VTE prophylaxis in hospitalized patients with HF. 12-15 Analysis of the Acute Decompensated Heart Failure National Registry revealed that of 71 376 patients eligible for VTE prophylaxis only 21 847 (31%) received prophylactic regimen. 16 An analysis of the PREMIER database showed that although 79% of 34 286 patients admitted with HF received an order for VTE prophylaxis, only 15.8% received recommended appropriate prophylactic regimen in terms of the type of medications, dose, and duration of therapy. 17 These data clearly demonstrate the need for increased awareness of prevention of VTE in hospitalized patients with HF. Therefore, the purpose of this article is to review the incidence, clinical significance, and preventive treatment of VTE in hospitalized patients with HF. Rationale for VTE Prophylaxis inHospitalized Patients With HF Risk Factors for VTE in HFIn general, hospitalized patients can exhibit many of the traditional risk factors for the development of VTE including surgery, trauma, immobility, malignancy, venous compression, previous VTE, advanced age, pregnancy, medications (especially estrogen and erythropoiesis stimulating agents), obesity, myeloproliferative disorders, and acute medical illness. 18 -22 Many of these are also apparent in the hospitalized patients with HF. Characteristics of patients from the Acute Decompensated Heart Failure National Registry, which includes Ͼ160 000 patient visits, reported a median age of Ͼ75 years, active malignancy in 5%, and history of stroke or transient ischemic attack in 17%. 23 Renal insufficiency and dialysis are also associated with an increased risk for deep venous thrombosis (DVT) and PE, 24 -27 and may be present in up to one third of hospitalized patients with HF. 23 Ischemic cardi...
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