Anomalous origin of the circumflex coronary artery from the right sinus of Valsalva is the most common coronary anomaly and is usually considered benign. Although several researchers in the past believed that aberrancy predisposes this vessel to accelerated atherosclerosis, this could not get wide acceptance owing to lack of convincing data. To examine the suggestion that atherosclerosis affects the anomalous circumflex artery more severely, the authors reviewed the clinical and angiographic features of patients with this anomaly identified from 2,684 coronary angiography procedures performed between January 1998 and March 2000 at their institution. The degree of atherosclerotic narrowing in the anomalous artery was compared with that in other coronary arteries in the same patient as well as in the nonanomalous circumflex arteries in controls. For comparison 3 control subjects were selected for each patient with anomalous circumflex artery, matched by age, sex, and clinical presentations. The results showed earlier and greater degree of atherosclerotic narrowing of the anomalous artery as compared to the other coronary arteries in the same patients as well as to nonanomalous circumflex arteries of age- and gender-matched control subjects with similar clinical characteristics. However, this predilection for atherosclerosis was evident only in anomalous vessels arising from the right side and pursuing a retroaortic course. The anomalous artery was responsible for myocardial infarction in 3 patients, all of whom were 60 years or older. Two of the patients with this anomaly and myocardial infarction underwent successful angioplasty with stent placement for symptomatic relief.
Administration of oral azithromycin, in addition to previously well-tolerated long-term amiodarone therapy, was associated with a marked prolongation of QT interval and increased QT dispersion, both substrates for life-threatening ventricular tachyarrhythmia and torsades de pointes. This is a report of QT prolongation and increased QT dispersion associated with the use of azithromycin. The report assumes an added significance, in view of widespread empirical use of this antibiotic for the treatment of lower respiratory infections and belief of its safety in patients with cardiac diseases. Based on the authors' experience, they would like to emphasize that the combination of azithromycin with other drugs known to prolong QT or causing torsades de pointes be used with caution until the question of the proarrhythmic effect of azithromycin is resolved by further studies.
Aortic stenosis (AS) is characterized as a high-risk index for cardiac complications during noncardiac surgery. The American College of Cardiology/American Heart Association guidelines define severe AS as aortic valve area ≤1 cm(2), mean gradient of ≥40 mm Hg, and peak velocity of ≥4 m/s. As per current clinical practice, any of these characteristic features label a patient as at high risk for noncardiac surgery. However, these parameters appear inconsistent, particularly with respect to the aortic valve area cutoff value. The perioperative risk associated with AS during noncardiac surgery depends upon its severity (moderate vs. severe), clinical status, and the complexity of the surgical procedure (low to intermediate risk vs. high risk). A critical analysis of old and new data from published studies indicates that the significance of the presence of AS in patients undergoing noncardiac surgery is overemphasized in studies that predate the more recent advances in echocardiography and cardiac catheterization in assessment of aortic stenosis, anesthetic and surgical techniques, as well as post-operative patient care.
Therapeutic advances in management of CHF have decreased mortality and have impacted progression in patients with mild to moderate heart failure. Aggressive campaigns by cardiology societies aimed at increasing implementation of these measures in routine practices have almost generalized the treatment of heart failure irrespective of individual variations of clinical status of patients and stages of heart failure. This explains why morbidity compression and quality of life improvement have not been realized fully particularly in patients with advanced disease. To examine whether GDMT for CHF is backed by unambiguous evidence of clinical efficacy for its global implementation in every patient at all stages of the syndrome. ACC/AHA, ESC Guidelines for CHF, and their updates were reviewed. Clinical trial cited in the guideline documents and other pertaining published literatures were analyzed.FindingsMany of the recommended GDMT for CHF lack unequivocal evidence of clinical efficacy in patients with diverge etiology of heart failure and concomitant comorbid conditions Some of the recommendations which are useful in early stages, lack evidence of efficacy in more advanced stages of heart failure. Application of results of research trials in patients beyond their inclusion and exclusion criteria, appears mere extrapolation, Clinicians are faced with the conundrum of implementing the recommendations without indubitable evidence of their efficacy in every patient of their practice.ConclusionA reappraisal of Guidelines is needed to address outstanding questions pertaining to the efficacy of recommendations and plug the knowledge gaps without assumption and extrapolation of results of RCTs beyond their inclusion and exclusion criteria.
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