A clinician's guide to a woman's heart.

Contrary to the perception of most women that breast cancer is the leading cause of death in women, it is heart disease and stroke that claim the most lives of women older than 35 years in the United States. The prevalence of cardiovascular disease is likely to increase as more women--notably the "baby boomers"--enter the menopausal period, a time of increased cardiac vulnerability. Primary care physicians should be on the forefront in taking an inventory of risk factors in their female patients and in educating them about the reality of heart disease in their gender and about the risk factors that these patients can modify to decrease their risk. To aid in their efforts, this article provides an overview of those risk factors that are modifiable, such as weight reduction, exercise, and smoking cessation. It also offers an evaluation of the benefit and nonbenefit of vitamin and herbal supplements in reduction of cardiac events.

Risk of catheter-related emboli in patients with atherosclerotic debris in the thoracic aorta.

The aim of this study was to evaluate the risk of performing cardiac catheterization or intraaortic balloon pump placement in patients with transesophageal echocardiographically detected atherosclerotic aortic debris. Cardiac catheterization was performed in 70 patients with atherosclerotic aortic debris (in 11 via the brachial approach and in 59 via the femoral approach) and in 71 control patients. An embolic event occurred in 10 (17%) of 59 patients with atherosclerotic aortic debris after femoral catheterization compared to 2 (3%) of 71 control patients without atherosclerotic aortic debris (p = 0.01). None of the 11 patients with atherosclerotic aortic debris who underwent brachial catheterization had an embolic event. An intraaortic balloon pump was placed in 10 patients with atherosclerotic aortic debris and in 12 control patients. An embolic event related to placement of the intraaortic balloon pump occurred in 5 (50%) of 10 patients with atherosclerotic aortic debris; no control patient had an embolic event (p = 0.02). Patients with mobile atherosclerotic aortic debris were at the highest risk for catheter-related embolism. The strongest clinical predictors of atherosclerotic aortic debris were advanced age and peripheral vascular disease. Transesophageal echocardiographic recognition of atherosclerotic aortic debris identifies patients at high risk of stroke or peripheral embolism after cardiac catheterization or intraaortic balloon pump placement. If the aortic debris is mobile, the risk is particularly high. When atherosclerotic aortic debris is detected, especially if the debris is mobile, substituting brachial for femoral catheterization and avoiding placement of an intraaortic balloon pump may reduce the risk of embolism.

Early repolarization: normalization of the electrocardiogram with exercise as a clinically useful diagnostic feature.

BACKGROUND: Early repolarization is a normal ECG variant which may resemble various pathologic conditions including acute myocardial infarction/injury and pericarditis. Some electrocardiographers believe early repolarization resolves with exercise-induced increases in heart rate. The purpose of this study was to evaluate qualitatively and quantitatively this phenomenon. METHODS: From among 3,000 consecutive patients referred for evaluation of ischemic heart disease by exercise treadmill testing, 25 patients with early repolarization and no risk factors for cardiovascular disease (Group I), 28 patients with early repolarization and risk factors for cardiovascular disease (Group IIA), and 28 matched control patients (Group IIB) were identified and evaluated retrospectively. Group II patients also underwent radionuclide stress imaging. All study patients had otherwise normal ECGs and a negative history of cardiovascular disease. RESULTS: In patients with early repolarization, diagnostic ST elevation was most frequently evident in ECG lead V4. We found that the ECG normalized progressively, beginning almost immediately with the onset of exercise, and typically returned completely to the isoelectric baseline at an average heart rate of approximately 106 beats per minute. In patients with otherwise normal ECGs and no history of cardiovascular disease, early repolarization was a strong predictor of a negative exercise treadmill test and only infrequently was associated with a positive radionuclide imaging study. Early repolarization was found in virtually all demographic groups with respect to age, race, and gender except for a disproportionate infrequency in white females. CONCLUSION: A progressive decrease in ST segment elevation and normalization of the ECG with mild exercise was a predictable response in patients who have early repolarization with otherwise normal ECGs and no history of cardiovascular disease. This phenomenon may be clinically useful as a bedside diagnostic tool in evaluating patients who present with early repolarization, otherwise normal ECGs, and negative cardiac history, in which the diagnosis of acute myocardial infarction/injury or pericarditis is being considered. These findings warrant formal evaluation in a prospective clinical trial.

Infections of implantable cardioverter defibrillators: approach to management.

Implantable cardioverter defibrillators are being used with increasing frequency for the treatment of life-threatening ventricular arrhythmias. Nevertheless, no guidelines exist for the management of infections of these devices. We report our experience with infections of these devices and review the English-language literature. In all cases, patients presented with local signs of generator infection; systemic signs of infection and bacteremia were often absent. Most infections are due to staphylococcus. Risk factors for the development of infection include placement of the device via median sternotomy during another cardiac surgical procedure, reoperation, and intercurrent infection at another site. Infections are most reliably treated with full explantation of the device and antibiotics. In rare cases, patients may respond to a combination of intravenous antibiotics and removal and replacement of only the generator.