SPECIAL PROBLEMS Prophylaxis for Infective Endocarditis in Objective-C

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SPECIAL PROBLEMS Prophylaxis for Infective Endocarditis
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Although there is no universal agreement, many authorities recommend antibiotic prophylaxis during labor for patients at risk for endocarditis, especially if forceps delivery is anticipated or episiotomy is performed Ampicillin (2 g intravenously or intramuscularly) plus gentamicin (15 mg/kg intravenously or intramuscularly [up to 80 mg]) followed by amoxicillin, 15 g orally every 6 hours, is the recommended regimen This area is undergoing extreme scrutiny, as the evidence that endocarditis can be prevented by prophylaxis therapy is lacking This is especially true for prophylaxis during delivery or with other gastrourinary procedures New recommendations from the AHA and ACC are due out shortly
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Management of Labor
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Although vaginal delivery is usually well tolerated, unstable patients (including patients with severe hypertension and worsening heart failure) should have planned cesarean section An increased risk of aortic rupture has been noted during delivery in patients with coarctation of the aorta and severe aortic root dilation with Marfan syndrome, and vaginal delivery should be avoided in these conditions For most patients, even those with congenital heart disease, vaginal delivery is preferred
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Elkayam U et al Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy N Engl J Med 2001 May 24;344(21):1567 71 [PMID: 11372007] Elkayam U et al Valvular heart disease and pregnancy part I: native valves J Am Coll Cardiol 2005 Jul 19;46(2):223 30 [PMID: 16022946] Elkayam U et al Valvular heart disease and pregnancy: part II: prosthetic valves J Am Coll Cardiol 2005 Aug 2;46(3):403 10 [PMID: 16053950] Head CE et al Congenital heart disease in pregnancy Postgrad Med J 2005 May;81(955):292 8 [PMID: 15879040] Lupton M et al Cardiac disease in pregnancy Curr Opin Obstet Gynecol 2002 Apr;14(2):137 43 [PMID: 11914690] Sliwa K et al Outcome of subsequent pregnancy in patients with documented peripartum cardiomyopathy Am J Cardiol 2004 Jun 1;93(11):1441 3 [PMID: 15165937]
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CARDIOVASCULAR SCREENING OF ATHLETES
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The sudden death of a competitive athlete inevitably becomes an occasion for local if not national publicity On each occasion, the public and the medical community ask whether such events could be prevented by more careful or complete screening Although each event is tragic, it must be appreciated that there are approximately 5 million competitive athletes at the high school level or above in any given year The number of cardiac
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Heart Disease
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Selective use of routine ECG and stress testing is recommended in men above age 40 years and women above age 50 years who continue to participate in vigorous exercise and at earlier ages when there is a positive family history for premature CAD, hypertrophic cardiomyopathy, or multiple risk factors
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Hosey RG Sudden cardiac death Clin Sports Med 2003 Jan;22 (1):51 66 [PMID: 12613086] Maron BJ et al; Working Groups of the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention; Councils on Clinical Cardiology and Cardiovascular Disease in
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CMDT 2008
the Young Recommendations for physical activity and recreational sports participation for young patients with genetic cardiovascular diseases Circulation 2004 Jun 8;109(22):2807 16 [PMID: 15184297]
ADDITIONAL READING
Specific information regarding symptoms and signs of heart disease, diagnostic testing, and techniques for evaluating rhythm disturbances appears in CMDT Online at http://wwwaccessmedicinecom
CMDT 2008
HOW IS BLOOD PRESSURE MEASURED AND HYPERTENSION DIAGNOSED
Systemic Hypertension
Michael Sutters, MD, MRCP (UK)
Sixty-six million Americans have elevated blood pressure (systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg); of these, 63% are aware of their diagnosis, but only 45% are receiving treatment and only 34% are under control using a threshold criterion of 140/90 mm Hg The prevalence of hypertension increases with age and is more common in blacks than in whites The mortality rates for stroke and coronary heart disease, two of the major complications of hypertension, have declined by 50 60% over the past three decades but have recently leveled off The numbers of patients with end-stage renal disease and heart failure two other conditions in which hypertension plays a major causative role continue to rise Cardiovascular morbidity and mortality increase as both systolic and diastolic blood pressures rise, but in individuals over age 50 years, the systolic pressure and pulse pressure are better predictors of complications than diastolic pressure Table 11 1 provides a summary of the classification and management of blood pressure in adults from the 7th Report of the US Joint National Commission on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)
Blood pressure should be measured with a well-calibrated sphygmomanometer The bladder width within the cuff should encircle at least 80% of the arm circumference Readings should be taken after the patient has been resting comfortably, back supported in the sitting or supine position, for at least 5 minutes and at least 30 minutes after smoking or coffee ingestion Hypertension is diagnosed when systolic blood pressure is consistently elevated above 140 mm Hg, or diastolic blood pressure is above 90 mm Hg; a single elevated blood pressure reading is not sufficient to establish the diagnosis of hypertension The major exceptions to this rule are hypertensive presentations with unequivocal evidence of lifethreatening end-organ damage, as seen in hypertensive emergency, or in hypertensive urgency where blood pressure is > 220/125 mm Hg but life-threatening end-organ damage is absent In less severe cases, the diagnosis of hypertension depends on a series of measurements of blood pressure, since
readings can vary and tend to regress toward the mean with time Patients whose initial blood pressure is in a hypertensive range exhibit the greatest fall toward the normal range between the first and second encounters Although blood pressure readings may still show variability after the third visit, these later changes are mostly random However, the concern for diagnostic precision needs to be balanced by an appreciation of the importance of establishing the diagnosis of hypertension as quickly as possible, since a 3-month delay in treatment of hypertension in high-risk patients is associated with a twofold increase in cardiovascular morbidity and mortality The guidelines of the 2005 Canadian Hypertension Education Program provide an algorithm designed to expedite the diagnosis of hypertension (Figure 11 1) To this end, they recommend short intervals between the initial office visits and stress the importance of early identification of target organ damage which, if present, obviates the need for protracted confirmation of blood pressure elevation prior to pharmacologic intervention In addition, the Canadian guidelines exploit the less volatile ambulatory and home blood pressure measurements as complements to office-based evaluations Hypertension is diagnosed at lower levels when based on measurements taken outside the office environment In addition to avoiding office-induced artifacts, ambulatory blood pressure measurements provide a more integrated view of blood pressure and the response to treatment There is now evidence that ambulatory measurements are more reliable predictors of cardiovascular risk than measurements taken in the office Blood pressure is normally lowest at night and the loss of this nocturnal dip is strongly associated with cardiovascular risk, particularly thrombotic stroke An accentuation of the normal morning increase in blood pressure is associated with increased likelihood of cerebral hemorrhage
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