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THE HYPERDYNAMIC STATE. MI with hyperdynamic state—that is, elevation of sinus rate, arterial pressure, and cardiac index, occurring singly or together in the presence of a normal or low left ventricular filling pressure—and if other causes of tachycardia such as fever, infection, and pericarditis can be excluded, treatment with beta blockers is indicated. Presumably, the increased heart rate and blood pressure are the result of inappropriate activation of the sympathetic nervous system, possibly secondary to augmented release of catecholamines, pain and anxiety, or some combination of these.
BEST CARDIOLOGY HOSPITALS IN BANGALORE Cardiac failure Cardiac failure is an increasingly common condition affecting about 1% of the population but much higher proportions of older people. It is responsible for an increasing number of hospital admissions. The various aetiologies have been discussed above, but the most common cause is now ischaemic heart disease rather than hypertensive heart disease. This reflects the improved modern management of hypertension in the population. The definition of heart failure has always included reference to the inability of the heart to meet the metabolic needs of the body. The earliest concepts of heart failure were of inadequate cardiac pump function and associated salt and water retention. Treatment was aimed at improving cardiac contractility and removing salt and water from the body. In the 1970s the concept of after-load reduction was introduced. This was based partly on the realisation that vasoconstriction was part of the problem. This has led to the modern neuro-hormonal concept of heart failure. It is clear that many of the features of cardiac failure are a result of stimulation of the renin-angiotensin-aldosterone system and sympathetic stimulation. These responses of the body to the fall in cardiac output temporarily increase cardiac performance and blood pressure by increasing vascular volumes, cardiac contractility and systemic resistance. In the medium and longer term these responses are maladaptive. They increase cardiac work and left ventricular volumes and lead to myocardial fibrosis with further loss of myocytes. Most recently it has become clear that heart failure is also an inflammatory condition, with evidence of cytokine activation. Work is underway to establish a role for treatment of this part of the condition. Current drug treatment has been successful in blocking many of the maladaptive aspects of neuro-hormonal stimulation. Many of these treatments have become established after benefits have been ascertained in large randomised controlled trials. These trials have also led to the abandoning of certain drugs (often those that increase cardiac performance) that were shown to have a detrimental effect on survival (e.g. Milrinone). The principles of treatment of heart failure are as follows: 1 Remove the exacerbating factors. 2 Relieve fluid retention. 3 Improve left ventricular function and reduce cardiac work; improve prognosis. 4 Protect against the adverse effects of drug treatment. 5 Assess for further management (e.g. revascularisation, transplant). 6 Manage complications (e.g. arrhythmias). 7 Protect high-risk patients from sudden death.
HEART DOCTORS IN BETTAHALASUR, BANGALIREHypertension and pregnancy Hypertension is the most common complication of pregnancy and remains an important cause of maternal and fetal mortality and morbidity. Hypertension in pregnancy can be classified as follows: 1 Chronic: existing hypertension with or without proteinuria. 2 Pre-eclampsia or eclampsia: proteinuria (> 300 mg/day) as well as new hypertension. Note that oedema is no longer part of the definition. 3 Pre-eclampsia in the context of existing hypertension: blood pressure higher than before pregnancy. 4 Gestational hypertension: new hypertension > 140/90 at least twice and after week 20 of pregnancy; no proteinuria. For most patients with existing hypertension the problem is just the blood pressure elevation. Pre-eclampsia, on the other hand, is a serious systemic disorder. It seems related to endothelial dysfunction due to failure of normal placental perfusion and the release of an unknown endothelial toxin. This causes vasospasm, reduced organ perfusion and eventually activation of the coagulation cascade. Superimposed pre-eclampsia occurs in up to 35% of women with pre-existing hypertension. These women are also at risk of abruptio placentae and cerebral haemorrhage. The fetus may also be affected by prematurity and there is an increased risk of still birth. Gestational hypertension does not involve proteinuria and if blood pressure returns to normal within 12 weeks of delivery, it is called
heart doctors in Doddabommasandra, Bangalore • Thrombolysis Contraindications to thrombolytic (fibrinolytic) treatment The following important contraindications to thrombolytic treatment must be considered rapidly before a decision to treat is made. They mostly relate to bleeding problems or risk. 1 Prolonged resuscitation following a cardiac arrest. Brief periods of cardiac massage should not prevent treatment. 2 Active peptic ulcer disease. 3 A recent surgical operation (up to 10 days, depending on the extent of the operation). 4 A previous haemorrhagic stroke. 5 Previous use of streptokinase probably means that agent should not be used again. Antibodies develop quickly and may cause allergic reactions and reduce the effectiveness of the drug. The usual approach is to use tissue plasminogen activator for these patients. 6 Diabetic retinopathy with a history of retinal haemorrhage. Thrombolytic treatment can be begun in the accident and emergency department or, if transfer is not delayed, in the CCU. Some successful trials of administration by ambulance officers have been conducted. This is especially useful if transfer to hospital is likely to take a long time. Staff in the department where the drug is given must be well informed about complications and their management. Some patients develop hypotension after the commencement of streptokinase. The drug infusion rate should then be slowed but not stopped. Reperfusion arrhythmias may develop in response to lysis (or balloon dilatation) of the thrombus. It is thought that metabolites washed from the ischaemic zone down the newly patent artery can cause electrical instability. These arrhythmias are usually self-limiting but occasionally ventricular tachycardia or fibrillation may occur. This is always awkward if it occurs in the lift on the way to the CCU. Other irregularities such as flurries of ventricular ectopics, periods of accelerated idioventricular rhythm (AIVR) or fascicular VT may occur. Successful thrombolysis may be difficult to diagnose at the bedside but the relief of pain,
heart doctors in Doddabommasandra, Bangalore • Thrombolysis Contraindications to thrombolytic (fibrinolytic) treatment The following important contraindications to thrombolytic treatment must be considered rapidly before a decision to treat is made. They mostly relate to bleeding problems or risk. 1 Prolonged resuscitation following a cardiac arrest. Brief periods of cardiac massage should not prevent treatment. 2 Active peptic ulcer disease. 3 A recent surgical operation (up to 10 days, depending on the extent of the operation). 4 A previous haemorrhagic stroke. 5 Previous use of streptokinase probably means that agent should not be used again. Antibodies develop quickly and may cause allergic reactions and reduce the effectiveness of the drug. The usual approach is to use tissue plasminogen activator for these patients. 6 Diabetic retinopathy with a history of retinal haemorrhage. Thrombolytic treatment can be begun in the accident and emergency department or, if transfer is not delayed, in the CCU. Some successful trials of administration by ambulance officers have been conducted. This is especially useful if transfer to hospital is likely to take a long time. Staff in the department where the drug is given must be well informed about complications and their management. Some patients develop hypotension after the commencement of streptokinase. The drug infusion rate should then be slowed but not stopped. Reperfusion arrhythmias may develop in response to lysis (or balloon dilatation) of the thrombus. It is thought that metabolites washed from the ischaemic zone down the newly patent artery can cause electrical instability. These arrhythmias are usually self-limiting but occasionally ventricular tachycardia or fibrillation may occur. This is always awkward if it occurs in the lift on the way to the CCU. Other irregularities such as flurries of ventricular ectopics, periods of accelerated idioventricular rhythm (AIVR) or fascicular VT may occur. Successful thrombolysis may be difficult to diagnose at the bedside but the relief of pain,
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