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THE BEST CARDIOLOGISTS IN YELAHANKA nvestigations of possible or probable stable angina Electrocardiography A standard 12-lead ECG should be obtained in all patients. This is likely to be normal in almost half of patients with subsequently proven coronary artery disease. Nevertheless, an abnormal trace lends weight to the symptoms and favours further investigation. Chest X-ray Routine radiology is not essential but may reveal important co-morbidities. It should always be performed in those with clinical evidence of hypertension, pericarditis (p. 174), heart failure or valvular disease, if only as a baseline. It is similarly indicated for patients with suspected or known pulmonary or systemic disease such as rheumatoid arthritis, COPD or alcoholism. Routine blood tests All patients with suspected angina should have the following routine investigations at presentation (NHF grade A recommendation): n fasting lipids, including total cholesterol, LDLs, HDLs and triglycerides—risk factors n fasting blood sugar—risk factor n full blood count—anaemia exacerbates angina n serum creatinine—impaired renal function is a risk factor and can be worsened by some cardiac investigations. If indicated clinically, thyroid function
Cardiologist in Doddaballapur Road, Bangalore • Investigations of possible or probable stable angina Electrocardiography A standard 12-lead ECG should be obtained in all patients. This is likely to be normal in almost half of patients with subsequently proven coronary artery disease. Nevertheless, an abnormal trace lends weight to the symptoms and favours further investigation. Chest X-ray Routine radiology is not essential but may reveal important co-morbidities. It should always be performed in those with clinical evidence of hypertension, pericarditis heart failure or valvular disease, if only as a baseline. It is similarly indicated for patients with suspected or known pulmonary or systemic disease such as rheumatoid arthritis, COPD or alcoholism. Routine blood tests All patients with suspected angina should have the following routine investigations at presentation (NHF grade A recommendation): fasting lipids, including total cholesterol, LDLs, HDLs and triglycerides—risk factors fasting blood sugar—risk factor full blood count—anaemia exacerbates angina serum creatinine—impaired renal function is a risk factor and can be worsened by some cardiac investigations. If indicated clinically, thyroid function tests should be ordered.
Cardiologist in Doddaballapur Road, Bangalore • Investigations of possible or probable stable angina Electrocardiography A standard 12-lead ECG should be obtained in all patients. This is likely to be normal in almost half of patients with subsequently proven coronary artery disease. Nevertheless, an abnormal trace lends weight to the symptoms and favours further investigation. Chest X-ray Routine radiology is not essential but may reveal important co-morbidities. It should always be performed in those with clinical evidence of hypertension, pericarditis heart failure or valvular disease, if only as a baseline. It is similarly indicated for patients with suspected or known pulmonary or systemic disease such as rheumatoid arthritis, COPD or alcoholism. Routine blood tests All patients with suspected angina should have the following routine investigations at presentation (NHF grade A recommendation): fasting lipids, including total cholesterol, LDLs, HDLs and triglycerides—risk factors fasting blood sugar—risk factor full blood count—anaemia exacerbates angina serum creatinine—impaired renal function is a risk factor and can be worsened by some cardiac investigations. If indicated clinically, thyroid function tests should be ordered.
Cardiology doctors in yelahanka New Town, Bangalore • Investigations of possible or probable stable angina Electrocardiography A standard 12-lead ECG should be obtained in all patients. This is likely to be normal in almost half of patients with subsequently proven coronary artery disease. Nevertheless, an abnormal trace lends weight to the symptoms and favours further investigation. Chest X-ray Routine radiology is not essential but may reveal important co-morbidities. It should always be performed in those with clinical evidence of hypertension, pericarditis , heart failure or valvular disease, if only as a baseline. It is similarly indicated for patients with suspected or known pulmonary or systemic disease such as rheumatoid arthritis, COPD or alcoholism. Routine blood tests All patients with suspected angina should have the following routine investigations at presentation (NHF grade A recommendation): fasting lipids, including total cholesterol, LDLs, HDLs and triglycerides—risk factors fasting blood sugar—risk factor full blood count—anaemia exacerbates angina serum creatinine—impaired renal function is a risk factor and can be worsened by som
THE BEST CARDIOLOGISTS IN YELAHANKA Indications for coronary angiography 1 Angina not responding to medical treatment in a patient without contraindications (e.g. extreme old age—usually older than about 85 these days—or severe co-morbidities) to cardiac surgery or angioplasty. 2 Continuing chest pain whose cause is not clear despite non-invasive investigations. The procedure may well be worthwhile if it reveals normal coronary arteries and prevents a patient being treated unnecessarily with more and more anti-anginal drugs. Non-invasive investigations are more often equivocal in women, and more women than men are found to have normal coronaries at angiography. 3 Preparation of a patient older than 35 or so for some other cardiac surgery (e.g. valve replacement). The surgeon needs to know whether significant coronary disease is present so that coronary grafting can be performed at the time of valve surgery. Otherwise, patients are at risk of ischaemic problems in the post-operative period. 4 Diagnosis of cardiomyopathy (p. 267) by excluding coronary artery disease and infarction as the cause of angina or cardiac failure. These patients may benefit from revascularisation if significant coronary disease is also present (‘ischaemic cardiomyopathy’). 5 Investigation of patients following myocardial infarction. Routine transfer to a centre with angiographic facilities after successful thrombolytic treatment is a grade D recommendation. There is no proof that a patient without continuing ischaemia has an improved prognosis when angiography and revascularisation are carried out routinely after infarction. The Open Artery Trial results suggest there is no benefit compared with optimal medical treatment for patients without ischaemic symptoms in having an occluded vessel opened five days or more after an infarction. However, spontaneous or induced ischaemia (by modified stress testing or perfusion imaging) leads to a grade B recommendation for angiography and intervention. The management of post-infarct patients is definitely easier if the coronary anatomy is known, and many units adopt the policy of early (within a week) angiography of infarct patients without contraindications to revascularisation. 6 Non-ST elevation acute coronary syndromes (p. 156). 7 Acute myocardial infarction in a unit where primary angioplasty can be performed
IHEART SPECIALISTS IN HEBBALA ndications for coronary angiography 1 Angina not responding to medical treatment in a patient without contraindications (e.g. extreme old age—usually older than about 85 these days—or severe co-morbidities) to cardiac surgery or angioplasty. 2 Continuing chest pain whose cause is not clear despite non-invasive investigations. The procedure may well be worthwhile if it reveals normal coronary arteries and prevents a patient being treated unnecessarily with more and more anti-anginal drugs. Non-invasive investigations are more often equivocal in women, and more women than men are found to have normal coronaries at angiography. 3 Preparation of a patient older than 35 or so for some other cardiac surgery (e.g. valve replacement). The surgeon needs to know whether significant coronary disease is present so that coronary grafting can be performed at the time of valve surgery. Otherwise, patients are at risk of ischaemic problems in the post-operative period. 4 Diagnosis of cardiomyopathy (p. 267) by excluding coronary artery disease and infarction as the cause of angina or cardiac failure. These patients may benefit from revascularisation if significant coronary disease is also present (‘ischaemic cardiomyopathy’). 5 Investigation of patients following myocardial infarction. Routine transfer to a centre with angiographic facilities after successful thrombolytic treatment is a grade D recommendation. There is no proof that a patient without continuing ischaemia has an improved prognosis when angiography and revascularisation are carried out routinely after infarction. The Open Artery Trial results suggest there is no benefit compared with optimal medical treatment for patients without ischaemic symptoms in having an occluded vessel opened five days or more after an infarction. However, spontaneous or induced ischaemia (by modified stress testing or perfusion imaging) leads to a grade B recommendation for angiography and intervention. The management of post-infarct patients is definitely easier if the coronary anatomy is known, and many units adopt the policy of early (within a week) angiography of infarct patients without contraindications to revascularisation. 6 Non-ST elevation acute coronary syndromes . 7 Acute myocardial infarction in a unit where primary angioplasty can be performed . Risks of cardiac catheterisation Cardiac catheterisation is an invasive procedure and patients must be aware of
POPULAR CARDIOLOGISTS IN KATTIGENAHALLI, BANGALORE Indications for coronary angiography 1 Angina not responding to medical treatment in a patient without contraindications (e.g. extreme old age—usually older than about 85 these days—or severe co-morbidities) to cardiac surgery or angioplasty. 2 Continuing chest pain whose cause is not clear despite non-invasive investigations. The procedure may well be worthwhile if it reveals normal coronary arteries and prevents a patient being treated unnecessarily with more and more anti-anginal drugs. Non-invasive investigations are more often equivocal in women, and more women than men are found to have normal coronaries at angiography. 3 Preparation of a patient older than 35 or so for some other cardiac surgery (e.g. valve replacement). The surgeon needs to know whether significant coronary disease is present so that coronary grafting can be performed at the time of valve surgery. Otherwise, patients are at risk of ischaemic problems in the post-operative period. 4 Diagnosis of cardiomyopathy (p. 267) by excluding coronary artery disease and infarction as the cause of angina or cardiac failure. These patients may benefit from revascularisation if significant coronary disease is also present (‘ischaemic cardiomyopathy’). 5 Investigation of patients following myocardial infarction. Routine transfer to a centre with angiographic facilities after successful thrombolytic treatment is a grade D recommendation. There is no proof that a patient without continuing ischaemia has an improved prognosis when angiography and revascularisation are carried out routinely after infarction. The Open Artery Trial results suggest there is no benefit compared with optimal medical treatment for patients without ischaemic symptoms in having an occluded vessel opened five days or more after an infarction. However, spontaneous or induced ischaemia (by modified stress testing or perfusion imaging) leads to a grade B recommendation for angiography and intervention. The management of post-infarct patients is definitely easier if the coronary anatomy is known, and many units adopt the policy of early (within a week) angiography of infarct patients without contraindications to revascularisation. 6 Non-ST elevation acute coronary syndromeS. 7 Acute myocardial infarction in a unit where primary angioplasty can be performed).
THE BEST HEART SPECIALIST IN YELAHANKA Indications for coronary angiography 1 Angina not responding to medical treatment in a patient without contraindications (e.g. extreme old age—usually older than about 85 these days—or severe co-morbidities) to cardiac surgery or angioplasty. 2 Continuing chest pain whose cause is not clear despite non-invasive investigations. The procedure may well be worthwhile if it reveals normal coronary arteries and prevents a patient being treated unnecessarily with more and more anti-anginal drugs. Non-invasive investigations are more often equivocal in women, and more women than men are found to have normal coronaries at angiography. 3 Preparation of a patient older than 35 or so for some other cardiac surgery (e.g. valve replacement). The surgeon needs to know whether significant coronary disease is present so that coronary grafting can be performed at the time of valve surgery. Otherwise, patients are at risk of ischaemic problems in the post-operative period. 4 Diagnosis of cardiomyopathy by excluding coronary artery disease and infarction as the cause of angina or cardiac failure. These patients may benefit from revascularisation if significant coronary disease is also present (‘ischaemic cardiomyopathy’). 5 Investigation of patients following myocardial infarction. Routine transfer to a centre with angiographic facilities after successful thrombolytic treatment is a grade D recommendation. There is no proof that a patient without continuing ischaemia has an improved prognosis when angiography and revascularisation are carried out routinely after infarction. The Open Artery Trial results suggest there is no benefit compared with optimal medical treatment for patients without ischaemic symptoms in having an occluded vessel opened five days or more after an infarction. However, spontaneous or induced ischaemia (by modified stress testing or perfusion imaging) leads to a grade B recommendation for angiography and intervention. The management of post-infarct patients is definitely easier if the coronary anatomy is known, and many units adopt the policy of early (within a week) angiography of infarct patients without contraindications to revascularisation. 6 Non-ST elevation acute coronary syndromes. 7 Acute myocardial infarction in a unit where primary angioplasty can be performed Risks
HEART DOCTORS IN YELAHANKA NEWTOWN, BANGALORE Management of ACS (NSTEACS) Patients with this diagnosis represent a rather heterogeneous group. Some have had the recent onset of angina at the extremes of exercise, others have angina at rest associated with ECG changes. This variation has made attempts to study the effects of different treatment rather difficult. Although the majority of patients with myocardial infarction have a preceding period of unstable angina, only about 5% of all patients admitted to hospital with a diagnosis of an ACS go on to infarct during that admission. The in-hospital mortality for these patients is low. Mortality rates of less than 2% are usual. Nevertheless, there is a real short-term and longerterm risk of infarction, recurrent admission with unstable symptoms and death which is higher than that of patients with stable angina. The diagnosis should therefore lead to admission to a CCU. The cardiac enzymes are, by definition, not elevated in these patients but the newer, more sensitive tests for troponin T and troponin I may be abnormal and indicate a worse prognosis . In the CCU, bed rest, oxygen and ECG monitoring are routinely enforced and any mobile phones taken away (allegedly to protect the monitoring equipment). Recurrence of chest pain can be assessed quickly and ECGs performed to look for changes suggesting infarction. The cardiac biomarkers can be checked regularly. All patients should receive aspirin (300 mg) unless there is a contraindication. Patients with an intermediate or a higher risk should also be given clopidogrel (usually a 300–600 mg loading dose). The use of intravenous heparin has become standard treatment. A typical starting dose is 5000 units as a bolus followed by 24, 000 units over 24 hours. The activated partial thromboplastin time (APPT) should be measured after about six hours of treatment and the infusion rate of heparin adjusted to maintain this at about twice normal. Heparin is generally safe when used in this way. Bleeding problems may sometimes occur and the platelet count should be checked every few days so that heparin-induced thrombocytopenia (HITS), a rare but serious complication, can be detected early. Low molecular weight heparins are at least as effective as unfractionated heparin. These drugs have some advantages over heparin. Their dose response effect is more predictable and they cause less thrombocytopenia. They are effective given subcutaneously without APPT monitoring and are now cheaper than IV heparin when savings on APPT monitoring and the use of infusion sets are considered. A standard twice-daily dose is given according to the patient’s weight—1 mg/kg for enoxaparin (Clexane). The dose is reduced by half for those with moderate or severe renal impairment and for those over the age of 75. Additional treatment should include beta-blockers unless these are contraindicated. These drugs reduce the number of ischaemic episodes and probably the risk of myocardial infarction. Nitrates can be a useful adjunctive treatment. They may be given orally, topically or intravenously. The IV dose can be titrated up or down depending on the amount of pain the patient is experiencing and the severity of side effects such as hypotension and headache. The problem of tachyphylaxis with nitrates can be overcome by steady increases in the IV dose if necessary. Calcium antagonists are appropriate treatment for patients intolerant of beta-blockers and may sometimes be added to beta-blockers. Nifedipine, especially in its short-acting form, should not be used for patients with acute coronary syndromes unless they are already taking beta-blockers. Thrombolytic drugs have been disappointing when used for NSTEACS. In trials where they have been used for patients with ischaemic chest pain but without ST elevation there has been a trend towards an adverse outcome. This may be related to the rebound hypercoagulable state that can occur after their use. In general they should not be used for the treatment of NSTEACS. Glycoprotein IIb/IIIa inhibitors (p. 198) should be given for high-risk patients,
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