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1
Walmsley, David. Cutaneous microvascular blood flow and function in non-ischaemic feet of normal and diabetic subjects. Birmingham: University of Birmingham, 1991.
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2
Valgimigli, Marco, and Marco Angelillis. Treatment of non-ST elevation acute coronary syndromes. Edited by Stefan James. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198784906.003.0311.
Full textAbstract:
Treatment of patients presenting with a non-ST elevation acute coronary syndrome (NSTE-ACS) aims at immediate relief of ischaemia and the prevention of serious adverse events, including death, myocardial (re)infarction, and life-threatening arrhythmias. In NSTE-ACS, patient management is guided by risk stratification (troponin, electrocardiogram, risk scores, etc.). Treatment options include anti-ischaemic and antithrombotic drugs and coronary revascularization including percutaneous coronary interventions, or coronary artery bypass grafting. While long-term secondary prevention with aspirin monotherapy is currently the gold standard approach for all NSTE-ACS patients who tolerate the drug, additional medications on top of aspirin such as oral P2Y12 inhibitors or oral anticoagulation have been investigated across clinical trials and their long-term use should be guided by the ischaemic versus bleeding risk status of each single individual patient.
3
Jood, Katarina, and Turgut Tatlisumak. Special aetiologies. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198722366.003.0006.
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The chapter ‘Special aetiologies of ischaemic stroke in young adults’ provides an overview of the broad spectrum of non-conventional causes of ischaemic stroke. It reviews the more common of these unusual conditions categorized as non-atherosclerotic non-inflammatory arteriopathies, non-atherosclerotic inflammatory arteriopathies, vasospastic syndromes, haematological disorders, genetic disorders, and miscellaneous disorders. It discusses strategies for aetiological diagnosis in young ischaemic stroke, provides a detailed overview of useful clinical clues obtained from patient history and physical examinations, and describes a patient-tailored step-wise diagnostic strategy based on clinical clues and findings from a group of basic diagnostic tests.
4
Bueno, Héctor, and José A. Barrabés. Non-ST-segment elevation acute coronary syndromes. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0046.
Full textAbstract:
Non-ST-segment elevation acute coronary syndromes are life-threatening disorders, usually caused by acute coronary thrombosis and subsequent myocardial ischaemia, presenting without persistent ST-segment elevation in the initial electrocardiogram. According to the occurrence of myocardial necrosis, non-ST-segment elevation acute coronary syndromes are divided into non-ST-segment myocardial infarction or unstable angina. The management of non-ST-segment elevation acute coronary syndromes requires an early diagnosis and risk stratification, urgent hospitalization, monitoring, and medical treatment, including antithrombotic therapy with dual antiplatelet therapy (aspirin plus one P2Y12 inhibitor) and parenteral anticoagulation, anti-ischaemic treatment, and preventative therapies. After the initial medical therapy is established, an invasive strategy, consisting of coronary angiography with coronary revascularization (either percutaneous coronary intervention or coronary bypass graft surgery), as appropriate, should be decided. The timing of the invasive strategy should be adjusted, according to the patient’s risk. Given the high event rate of patients with non-ST-segment elevation acute coronary syndromes after hospital discharge, an aggressive long-term preventative therapy should be put in place to improve prognosis.
5
Bueno, Héctor, and José A. Barrabés. Non-ST-segment elevation acute coronary syndromes. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0046_update_001.
Full textAbstract:
Non-ST-segment elevation acute coronary syndromes are life-threatening disorders, usually caused by acute coronary thrombosis and subsequent myocardial ischaemia, presenting without persistent ST-segment elevation in the initial electrocardiogram. According to the occurrence of myocardial necrosis, non-ST-segment elevation acute coronary syndromes are divided into non-ST-segment myocardial infarction or unstable angina. The management of non-ST-segment elevation acute coronary syndromes requires an early diagnosis and risk stratification, urgent hospitalization, monitoring, and medical treatment, including antithrombotic therapy with dual antiplatelet therapy (aspirin plus one P2Y12 inhibitor) and parenteral anticoagulation, anti-ischaemic treatment, and preventative therapies. After the initial medical therapy is established, an invasive strategy, consisting of coronary angiography with coronary revascularization (either percutaneous coronary intervention or coronary bypass graft surgery), as appropriate, should be decided. The timing of the invasive strategy should be adjusted, according to the patient’s risk. Given the high event rate of patients with non-ST-segment elevation acute coronary syndromes after hospital discharge, an aggressive long-term preventative therapy should be put in place to improve prognosis.
6
Bueno, Héctor, and José A. Barrabés. Non-ST-segment elevation acute coronary syndromes. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0046_update_002.
Full textAbstract:
Non-ST-segment elevation acute coronary syndromes are life-threatening disorders, usually caused by acute coronary thrombosis and subsequent myocardial ischaemia, presenting without persistent ST-segment elevation in the initial electrocardiogram. According to the occurrence of myocardial necrosis, non-ST-segment elevation acute coronary syndromes are divided into non-ST-segment myocardial infarction or unstable angina. The management of non-ST-segment elevation acute coronary syndromes requires an early diagnosis and risk stratification, urgent hospitalization, monitoring, and medical treatment, including antithrombotic therapy with dual antiplatelet therapy (aspirin plus one P2Y12 inhibitor) and parenteral anticoagulation, anti-ischaemic treatment, and preventative therapies. After the initial medical therapy is established, an invasive strategy, consisting of coronary angiography with coronary revascularization (either percutaneous coronary intervention or coronary bypass graft surgery), as appropriate, should be decided. The timing of the invasive strategy should be adjusted, according to the patient’s risk. Given the high event rate of patients with non-ST-segment elevation acute coronary syndromes after hospital discharge, an aggressive long-term preventative therapy should be put in place to improve prognosis.
7
Alonso Salinas, Gonzalo Luis, Marina Pascual Izco, Covadonga Fernández-Golfín, Luigi P. Badano, and José Luis Zamorano. Ischaemic heart disease: acute coronary syndrome. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198726012.003.0029.
Full textAbstract:
Transthoracic echocardiography (TTE) is a non-invasive and accessible tool that should be widely used in the evaluation of patients with suspected or known acute coronary syndrome (ACS). Its role is crucial in the management of patients with suspected ACS without electrocardiographic changes or elevation of cardiac markers, allowing the formulation of differential diagnosis between cardiac and extracardiac aetiologies. If the ACS is confirmed, initial assessment of regional and global left and right ventricle contractile function is fundamental in establishing the management strategy and may help in the risk stratification of these patients. TTE can also characterize the ischaemic myocardium in the acute phase, exposing any myocardial regional wall motion abnormalities. Furthermore, TTE is an excellent tool for the initial assessment of the aetiology of cardiogenic shock. It provides additional information regarding the haemodynamic status of the patient, including filling pressures and stroke volume, and it may rule out other causes of shock; thus, immediate TTE, or transoesophageal echocardiography if necessary, should be performed when cardiogenic shock is suspected. In the chronic phase, TTE plays an important role in characterizing myocardial infarction scar and its extent. TTE can accurately differentiate viable myocardium from scar tissue, and may guide revascularization if needed, improving patient care.
8
Lancellotti, Patrizio, and Bernard Cosyns. Stress Echocardiography. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713623.003.0016.
Full textAbstract:
Stress echocardiography is well established in patients with ischaemic and has gained growing interest in non-ischaemic heart disease. Indications for stress echocardiography are grouped in very broad categories to encompass the overwhelming majority of patients. These include; coronary artery disease diagnosis, prognosis and risk stratification in patients with established diagnosis (for example, after myocardial infarction), preoperative risk assessment, evaluation for cardiac aetiology of exertional dyspnoea, assessment of pulmonary hypertension, evaluation after revascularization, Ischaemia location, and evaluation of heart valve stenosis severity, athletes’ hearts or heart transplants.
9
Katritsis, Demosthenes G., Bernard J. Gersh, and A. John Camm. Epidemiology and pathophysiology of coronary artery disease. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199685288.003.0529_update_004.
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This chapter presents the epidemiology and pathophysiology of stable ischaemic heart disease and acute coronary syndromes, i.e. unstable angina/non-ST elevation myocardial infarction and ST elevation myocardial infarction.
10
Ratliff, David. Limb ischaemia. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0067.
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Acute limb ischaemia is defined as a decrease in the arterial blood flow, over a period of minutes to days, which threatens the viability of the limb. Presentation is within 2 weeks of the onset of symptoms. Chronic limb ischaemia (presentation >2 weeks after the onset of symptoms) can be divided into critical ischaemia—a potential threat to limb viability, with ischaemic rest pain, ischaemic ulcers, or gangrene—and non-critical ischaemia, which may be symptomatic (typically with claudication) or asymptomatic. This chapter discusses limb ischaemia, including differential diagnosis, context, approach to diagnosis, specific clues to the diagnosis, key diagnostic tests, treatment and therapy, prognosis, and how to handle uncertainty in the diagnosis of the symptom.
11
Muneer, Asif, and David Ralph. Priapism. Edited by David John Ralph. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199659579.003.0106.
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Priapism is rare and is a medical emergency. Ischaemic priapism is the commonest subtype with haematological abnormalities, psychotropic or recreational drug use and malignancy being the other common aetiologies. Emergency decompression of this compartment syndrome is required to preserve cavernosal smooth muscle function and this should ideally be performed as soon as possible. The degree of resultant erectile dysfunction is related to the duration of the priapism. Non-ischaemic priapism is an unregulated inflow of arterial blood, often as a result of perineal trauma and a lacerated cavernosal vessel. Selective arterial embolization should be performed and results are usually excellent. The final subtype is stuttering priapism, the cause of which is often unknown and a variety of methods will be discussed for its treatment.
12
Balik, Martin. Perioperative cardiac care of the high-risk non-cardiac patient. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0076.
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Non-cardiac surgery conveys a cardiac risk related to the status of the patient’s cardiovascular system. Cardiac-related risk of surgery can be assessed by integrating the risk and urgency of the procedure with cardiovascular risk factors, which include age, ischaemic heart disease, heart failure, stroke, diabetes mellitus, chronic obstructive pulmonary disease, and renal dysfunction. An individual assessment can include simple multivariate scoring systems, developed with the aim of evaluating cardiac risk prior to non-cardiac surgery. Patient assessment can be extended for indicated additional tests. The indications for further cardiac testing and treatments are the same as in the non-operative setting, but their timing is dependent on the urgency of surgery, and patient-specific and surgical risk factors. A delay in surgery, due to the use of both non-invasive and invasive preoperative testing, should be limited to those circumstances in which the results of such tests will clearly affect patient management. In high-risk patients, the result of the cardiac assessment helps to choose adequate perioperative monitoring and to indicate for an intensive care unit stay perioperatively. Chronic medications can be adjusted, according to the current knowledge on perioperative management. Drugs with the potential to reduce the incidence of post-operative cardiac events and mortality include beta-blockers, statins, and aspirin. Chronic platelet anti-aggregation and anticoagulation therapies have to be adapted by weighing the risk of bleeding against the risk of thrombotic complications.
13
Balik, Martin. Perioperative cardiac care of the high-risk non-cardiac patient. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0076_update_001.
Full textAbstract:
Non-cardiac surgery conveys a cardiac risk related to the status of the patient’s cardiovascular system. Cardiac-related risk of surgery can be assessed by integrating the risk and urgency of the procedure with cardiovascular risk factors, which include age, ischaemic heart disease, heart failure, stroke, diabetes mellitus, chronic obstructive pulmonary disease, and renal dysfunction. An individual assessment can include simple multivariate scoring systems, developed with the aim of evaluating cardiac risk prior to non-cardiac surgery. Patient assessment can be extended for indicated additional tests. The indications for further cardiac testing and treatments are the same as in the non-operative setting, but their timing is dependent on the urgency of surgery, and patient-specific and surgical risk factors. A delay in surgery, due to the use of both non-invasive and invasive preoperative testing, should be limited to those circumstances in which the results of such tests will clearly affect patient management. In high-risk patients, the result of the cardiac assessment helps to choose adequate perioperative monitoring and to indicate for an intensive care unit stay perioperatively. Chronic medications can be adjusted, according to the current knowledge on perioperative management. Drugs with the potential to reduce the incidence of post-operative cardiac events and mortality include beta-blockers, statins, and aspirin. Chronic platelet anti-aggregation and anticoagulation therapies have to be adapted by weighing the risk of bleeding against the risk of thrombotic complications.
14
Balik, Martin. Perioperative cardiac care of the high-risk non-cardiac patient. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0076_update_002.
Full textAbstract:
Non-cardiac surgery conveys a cardiac risk related to the status of the patient’s cardiovascular system. Cardiac-related risk of surgery can be assessed by integrating the risk and urgency of the procedure with cardiovascular risk factors, which include age, ischaemic heart disease, heart failure, stroke, diabetes mellitus, chronic obstructive pulmonary disease, and renal dysfunction. An individual assessment can include simple multivariate scoring systems, developed with the aim of evaluating cardiac risk prior to non-cardiac surgery. Patient assessment can be extended for indicated additional tests. The indications for further cardiac testing and treatments are the same as in the non-operative setting, but their timing is dependent on the urgency of surgery, and patient-specific and surgical risk factors. A delay in surgery, due to the use of both non-invasive and invasive preoperative testing, should be limited to those circumstances in which the results of such tests will clearly affect patient management. In high-risk patients, the result of the cardiac assessment helps to choose adequate perioperative monitoring and to indicate for an intensive care unit stay perioperatively. Chronic medications can be adjusted, according to the current knowledge on perioperative management. Drugs with the potential to reduce the incidence of post-operative cardiac events and mortality include beta-blockers, statins, and aspirin. Chronic platelet anti-aggregation and anticoagulation therapies have to be adapted by weighing the risk of bleeding against the risk of thrombotic complications.
15
Rady, Mohamed Y., and Ari R. Joffe. Non-heart-beating organ donation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0390.
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The transplantation community endorses controlled and uncontrolled non-heart-beating organ donation (NHBD) to increase the supply of transplantable organs at end of life. Cardiac arrest must occur within 1–2 hours after the withdrawal of life-support in controlled NHBD. Uncontrolled NHBD is performed after failed cardiopulmonary resuscitation in an unexpected witnessed cardiac arrest. Donor management aims to protect transplantable organs against warm ischaemic injury through the optimization of haemodynamics and mechanical ventilation. This also requires antemortem instrumentation and systemic anticoagulation for organ perseveration in controlled NHBD. Interval support with extracorporeal membrane oxygenation or cardiopulmonary bypass is generally required for optimal organ perfusion and oxygenation in uncontrolled NHBD, which remains a controversial medical practice. There are several unresolved ethical challenges. The circulatory criterion of 2–10 minutes of absent arterial pulse does not comply with the uniform determination of death criterion of the irreversible cessation of functions of the cardiovascular or central nervous systems. There are no robust safeguards in clinical practice that can prevent faulty prognostication, and premature withdrawal of treatment or termination of cardiopulmonary resuscitation. Unmanaged conflicting interests of increasing the supply of transplantable organs can have serious consequences on the medical care of potentially salvageable patients. Perimortem interventions can interfere with the delivery of an optimal quality of end-of-life care. The lack of disclosure of these NHBD ethical controversies does not uphold the moral obligation for an informed consent.
16
Ruiz-Villalba, Adrián, Nikolaos Frangogiannis, and José Maria Pérez-Pomares. Origin and diversity of cardiac fibroblasts: developmental substrates of adult cardiac fibrosis. Edited by José Maria Pérez-Pomares, Robert G. Kelly, Maurice van den Hoff, José Luis de la Pompa, David Sedmera, Cristina Basso, and Deborah Henderson. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198757269.003.0012.
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Cardiac connective tissues are primarily formed by cardiac fibroblasts (CF) of diverse embryonic origins. Whereas CF specific roles in cardiac morphogenesis remain under-researched, their involvement in adult cardiac fibrosis is clinically relevant. Cardiac fibrosis is a common element of several chronic cardiac conditions characterized by the loss of ventricular wall mechanical function, ultimately driving to heart failure. In the ischaemic heart early reparative fibrosis evidences the very restricted regenerative potential of the myocardium. In non-ischaemic diseases fibrosis is activated by unknown signals. We summarize current knowledge on the origin of CFs and their developmental roles, and discuss the differential disease-dependent response of different CF subpopulations to various pathological stimuli. We also describe the characteristic cell-cell and cell-matrix interactions that determine the fibrotic remodelling of the myocardium. We analyse experimental models for the study of cardiac fibrosis, and suggest future directions in the search for new markers and therapeutic targets.
17
Gimelli, Alessia, and Riccardo Liga. Basic principles and technological state of the art: SPECT. Edited by Philipp Kaufmann. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198784906.003.0119.
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Single-photon emission computed tomography (SPECT) photons as a medical imaging technique detects the radiation emitted by radioisotopes injected into the body to provide in vivo measurements of regional tissue function. From its introduction in the cardiologic clinical field, nuclear imaging has classically represented the reference technique for the non-invasive evaluation of myocardial perfusion, becoming the most frequently performed imaging modality for the functional assessment of patients with ischaemic heart disease.
18
Lameire, Norbert. Prevention of acute kidney injury. Edited by Norbert Lameire. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199592548.003.0225_update_001.
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This chapter describes the most important non-pharmacologic interventions in the prevention of acute kidney injury. Specific for bypass surgery is the choice between on- versus off-pump surgery in coronary artery bypass grafting. Other interventions include optimization and maintenance of oxygen delivery and of cardiovascular haemodynamics; careful selection of fluid therapy, particularly in septic shock and the postoperative period; possible application of preoperative remote ischaemic preconditioning; maintaining euglycaemia, and application of lung-protective artificial ventilation.
19
Leys, Didier, Charlotte Cordonnier, and Valeria Caso. Stroke. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0067.
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Stroke is a major public health issue. Many are treatable in the acute stage, provided patients are admitted soon enough. The overall incidence of stroke in Western countries is approximately 2400 per year per million inhabitants, and 80% are due to cerebral ischaemia. The prevalence is approximately 12 000 per million inhabitants. Stroke is associated with increased long-term mortality, handicap, cognitive and behavioural impairments, recurrence, and an increased risk of other types of vascular events. It is of major interest to take the heterogeneity of stroke into account, because of differences in the acute management, secondary prevention, and outcomes, according to the subtype and cause of stroke. In all types of stroke, early epileptic seizures, delirium, increased intracranial pressure, and non-specific complications are frequent. In ischaemic strokes, specific complications, such as malignant infarcts, spontaneous haemorrhagic transformation, early recurrence, and a new ischaemic event in another vascular territory, are frequent. In haemorrhagic strokes, the major complication is the subsequent increased volume of bleeding. There is strong evidence that stroke patients should be treated in dedicated stroke units; each time 24 patients are treated in a stroke unit, instead of a conventional ward, one death and one dependence are prevented. This effect does not depend on age, severity, and the stroke subtype. For this reason, stroke unit care is the cornerstone of the treatment of stroke, aiming at the detection and management of life-threatening emergencies, stabilization of most physiological parameters, and prevention of early complications. In ischaemic strokes, besides this general management, specific therapies include intravenous recombinant tissue plasminogen activator, given as soon as possible and before 4.5 hours, otherwise aspirin 300 mg, immediately or after 24 hours in case of thrombolysis, and, in a few patients, decompressive surgery. In intracerebral haemorrhages, blood pressure lowering and haemostatic therapy, when needed, are the two targets, but surgery does not seem effective to reduce death and disability.
20
Leys, Didier, Charlotte Cordonnier, and Valeria Caso. Stroke. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0067_update_001.
Full textAbstract:
Stroke is a major public health issue. Many are treatable in the acute stage, provided patients are admitted soon enough. The overall incidence of stroke in Western countries is approximately 2400 per year per million inhabitants, and 80% are due to cerebral ischaemia. The prevalence is approximately 12 000 per million inhabitants. Stroke is associated with increased long-term mortality, handicap, cognitive and behavioural impairments, recurrence, and an increased risk of other types of vascular events. It is of major interest to take the heterogeneity of stroke into account, because of differences in the acute management, secondary prevention, and outcomes, according to the subtype and cause of stroke. In all types of stroke, early epileptic seizures, delirium, increased intracranial pressure, and non-specific complications are frequent. In ischaemic strokes, specific complications, such as malignant infarcts, spontaneous haemorrhagic transformation, early recurrence, and a new ischaemic event in another vascular territory, are frequent. In haemorrhagic strokes, the major complication is the subsequent increased volume of bleeding. There is strong evidence that stroke patients should be treated in dedicated stroke units; each time 24 patients are treated in a stroke unit, instead of a conventional ward, one death and one dependence are prevented. This effect does not depend on age, severity, and the stroke subtype. For this reason, stroke unit care is the cornerstone of the treatment of stroke, aiming at the detection and management of life-threatening emergencies, stabilization of most physiological parameters, and prevention of early complications. In ischaemic strokes, besides this general management, specific therapies include intravenous recombinant tissue plasminogen activator, given as soon as possible and before 4.5 hours, otherwise aspirin 300 mg, immediately or after 24 hours in case of thrombolysis, and, in a few patients, decompressive surgery. In intracerebral haemorrhages, blood pressure lowering and haemostatic therapy, when needed, are the two targets, but surgery does not seem effective to reduce death and disability.
21
Leys, Didier, Charlotte Cordonnier, and Valeria Caso. Stroke. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199687039.003.0067_update_002.
Full textAbstract:
Stroke is a major public health issue. Many are treatable in the acute stage, provided patients are admitted soon enough. The overall incidence of stroke in Western countries is approximately 2400 per year per million inhabitants, and 80% are due to cerebral ischaemia. The prevalence is approximately 12 000 per million inhabitants. Stroke is associated with increased long-term mortality, handicap, cognitive and behavioural impairments, recurrence, and an increased risk of other types of vascular events. It is of major interest to take the heterogeneity of stroke into account, because of differences in the acute management, secondary prevention, and outcomes, according to the subtype and cause of stroke. In all types of stroke, early epileptic seizures, delirium, increased intracranial pressure, and non-specific complications are frequent. In ischaemic strokes, specific complications, such as malignant infarcts, spontaneous haemorrhagic transformation, early recurrence, and a new ischaemic event in another vascular territory, are frequent. In haemorrhagic strokes, the major complication is the subsequent increased volume of bleeding. There is strong evidence that stroke patients should be treated in dedicated stroke units; each time 24 patients are treated in a stroke unit, instead of a conventional ward, one death and one dependence are prevented. This effect does not depend on age, severity, and the stroke subtype. For this reason, stroke unit care is the cornerstone of the treatment of stroke, aiming at the detection and management of life-threatening emergencies, stabilization of most physiological parameters, and prevention of early complications. In ischaemic strokes, besides this general management, specific therapies include intravenous recombinant tissue plasminogen activator, given as soon as possible and before 4.5 hours, mechanical thrombectomy in case of proximal occlusion (middle cerebral artery, intracranial internal carotid artery, basilar artery), on top of thrombolysis in the absence of contraindication or alone otherwise, aspirin 300 mg, immediately or after 24 hours in case of thrombolysis, and, in a few patients, decompressive surgery. In intracerebral haemorrhages, blood pressure lowering and haemostatic therapy, when needed, are the two targets, while surgery does not seem effective to reduce death and disability.
22
Koutroumanidis, Michalis, and Robin Howard. Encephalopathy, central nervous system infections, and coma. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199688395.003.0032.
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This chapter provides an overview of the indications for and the diagnostic and prognostic value of acute video-electroencephalogram (EEG) and continuous video-EEG monitoring in patients with encephalopathies, encephalitides, and coma. Particular emphasis is placed on the detection of non-convulsive seizures and non-convulsive status epilepticus secondary to acute and sub-acute cerebral insults, including post-cardiac arrest hypoxic-ischaemic brain injury, and on the related pitfalls and uncertainties. It also discusses key technical aspects of the EEG recording, including artefact identification and limitation, timing and type of external stimulation and assessment of EEG reactivity, and highlights the main relevant pitfalls. Finally, it explores the role of evoked potentials (EPs) in outcome prediction and the value of Cognitive EPs and quantitative EEG in the assessment of chronic disorders of consciousness.
23
Prout, Jeremy, Tanya Jones, and Daniel Martin. Cardiovascular system. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199609956.003.0001.
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This chapter covers the assessment and investigation of perioperative cardiac risk, the principles of perioperative haemodynamic monitoring and physiological changes in cardiac comorbidity with their relevance to anaesthetic management. Perioperative cardiovascular risk includes assessment of cardiac risk factors, functional capacity and evidence-based guidelines for preassessment. Cardiovascular investigations such as cardiopulmonary exercise testing and scoring systems for cardiac risk are included. Management of the cardiac patient for non-cardiac surgery is detailed. Invasive monitoring with arterial, central venous and pulmonary artery catheters is described. Cardiac output measurement systems including dilution techniques, pulse contour analysis and Doppler are compared. The physiological changes, management and implications for anaesthesia of common cardiac comorbidity including ischaemic heart disease, heart failure, valvular heart disease, pacemakers and pulmonary hypertension are described.
24
Peppelenbosch, A. G., and Martijn Poeze. Ischaemic bowel in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0186.
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Intestinal ischaemia is caused by occlusion of the visceral arteries, thrombosis of the mesenteric veins, or by (low-flow) non-occlusive mesenteric ischaemia (NOMI). Each condition has a specific diagnostic and therapeutic work-up and prognostic significance. The incidence of acute mesenteric infarction is as low as 0.63 cases/100,000 person years, but overall mortality rates remains high at 74%. In general, a high index of suspicion is necessary and should be followed by administering therapeutic low molecular weight heparin or systemic heparin infusion. In these patients resuscitation and organ support are essential, but should not delay diagnostic work-up, including CT-angiography. With arterial occlusion, revascularization should be performed if indicated, preferentially using endovascular techniques prior to laparotomy. For venous occlusion, thrombolytic therapy directly into the superior mesenteric artery or venous thrombectomy can be performed, followed by laparotomy. The treatment of NOMI is to treat the underlying cause.
25
Lancellotti, Patrizio, and Bernard Cosyns. Cardiac Source of Embolism (SOE) and Cardiac Masses. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713623.003.0014.
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Embolism of cardiac origin accounts for around 15–30 per cent of ischaemic strokes. The diagnosis of a cardio-embolic source of stroke is frequently uncertain and relies on the identification of a potential cardiac source of embolism in the absence of significant cerebrovascular occlusive disease. In this respect, echocardiography (both transthoracic and/or transoesophageal) serves as a cornerstone in the evaluation, diagnosis, and managementof these patients. A clear understanding of the various types of cardiac conditions associated with cardio-embolic stroke and their intrinsic risk is therefore very important. This chapter describes three categories of cardio-embolic sources of embolism: conditions predisposing to thrombus formation; cardiac masses; and cardiac conduits for paradoxical embolization. It focuses on cardiac masses and potential sources of embolism including vegetations, thrombi, cardiac tumours, non-neoplastic masses, extracardiac masses, suggesting differential diagnosis with structures that may mime pathologic conditions.
26
Rantanen, Kirsi, and Karoliina Aarnio. Stroke in women. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198722366.003.0012.
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Young women who suffer from stroke face multiple challenges regarding child rearing, future pregnancies, and ability to return to work or education. Women in general have a higher lifetime risk of stroke than men (1 in 5 vs 1 in 6), which is partly explained by longer life expectancy in the female population. The incidence of ischaemic stroke in non-pregnant women aged 15–44 years has been around 5 per 100,000 women-years. Women have lower stroke mortality than men except in the older age groups. Women have unique stroke risk factors such as oral contraception, pregnancy, puerperium, and menopausal hormone therapy. It remains unresolved why oestrogen, thought to be neuroprotective, actually can turn out to be harmful in regard to stroke risk. A number of major stroke risk factors such as hypertension, migraine with aura, obesity, metabolic syndrome, and atrial fibrillation are more common in women than men.
27
Gattringer, Thomas, Christian Enzinger, Stefan Ropele, and Franz Fazekas. Vascular imaging (CTA/MRA). Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198722366.003.0008.
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Non-invasive computed tomography angiography (CTA) and magnetic resonance angiography (MRA) constitute an integral part of the diagnostic workup of stroke patients, which—among the various techniques to image the complex cerebrovascular tree—can be conceptually placed between duplex sonography and digital subtraction angiography. CTA and especially MRA can be performed with different techniques and protocols that need to be used according to the clinical questions. In the setting of acute ischaemic stroke with the therapeutic option of endovascular thrombectomy, the rapid and reliable detection of large vessel occlusion has become of paramount importance. Both CTA and MRA can accomplish this and there is no need for contrast material when performing intracranial MRA. Vascular imaging is also essential to identify vessel-related causes of stroke such as large artery atherosclerosis, dissection, and some forms of arteritis mandating specific management or therapeutic intervention to avoid recurrence. Considering these aspects, frequent and targeted use of CTA or MRA is highly encouraged and especially relevant in young patients with stroke.
28
Andrade, Maria João, and Albert Varga. Stress echocardiography: methodology. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198726012.003.0012.
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Stress echocardiography is the combination of echocardiography with a physical, pharmacological, or electrical stress. Good quality images are absolutely necessary and a quad-screen format should be applied for comparative analysis. Different stress echo protocols can be used in different pathologies. Exercise echocardiography has the advantages of its wide availability, low cost, and versatility for the assessment of various cardiac conditions. The most usual pathologies are suspected or known ischaemic heart disease, mitral and aortic valve diseases, hypertrophic cardiomyopathy, and pulmonary hypertension. Among exercise-independent stresses, dobutamine and dipyridamole are the most frequently used. Dobutamine is widely accepted for the evaluation of myocardial viability. The two tests have comparable accuracy for the detection of coronary artery disease. Ergonovine echo is highly feasible, accurate, and safe for the diagnosis of coronary vasospasm. High-rate pacing is especially appropriate in patients with a permanent pacemaker because non-invasive diagnosis of coronary artery disease in these patients is an extremely difficult task.
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De Deyne, Cathy, and Jo Dens. Neurological assessment of the acute cardiac care patient. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0016.
Full textAbstract:
Many techniques are currently available for cerebral physiological monitoring in the intensive cardiac care unit environment. The ultimate goal of cerebral monitoring applied during the acute care of any patient with/or at risk of a neurological insult is the early detection of regional or global hypoxic/ischaemic cerebral insults. In the most ideal situation, cerebral monitoring should enable the detection of any deterioration before irreversible brain damage occurs or should at least enable the preservation of current brain function (such as in comatose patients after cardiac arrest). Most of the information that affects bedside care of patients with acute neurologic disturbances is now derived from clinical examination and from knowledge of the pathophysiological changes in cerebral perfusion, cerebral oxygenation, and cerebral function. Online monitoring of these changes can be realized by many non-invasive techniques, without neglecting clinical examination and basic physiological variables such as invasive arterial blood pressure monitoring or arterial blood gas analysis.
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De Deyne, Cathy, Ward Eertmans, and Jo Dens. Neurological assessment of the acute cardiac care patient. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0016_update_001.
Full textAbstract:
Many techniques are currently available for cerebral physiological monitoring in the intensive cardiac care unit environment. The ultimate goal of cerebral monitoring applied during the acute care of any patient with/or at risk of a neurological insult is the early detection of regional or global hypoxic/ischaemic cerebral insults. In the most ideal situation, cerebral monitoring should enable the detection of any deterioration before irreversible brain damage occurs or should at least enable the preservation of current brain function (such as in comatose patients after cardiac arrest). Most of the information that affects bedside care of patients with acute neurologic disturbances is now derived from clinical examination and from knowledge of the pathophysiological changes in cerebral perfusion, cerebral oxygenation, and cerebral function. Online monitoring of these changes can be realized by many non-invasive techniques, without neglecting clinical examination and basic physiological variables—with possible impact on optimal cerebral perfusion/oxygenation—such as invasive arterial blood pressure monitoring or arterial blood gas analysis.
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Neary, John, and Neil Turner. The patient with haematuria. Edited by Neil Turner. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0046.
Full textAbstract:
Haematuria is a common presenting feature of diseases of the kidney or the renal tract. It is also common in screening tests, single dipstick tests being positive in perhaps 5% of individuals. Age and whether the blood is visible (macroscopic) or non-visible (microscopic) impact largely on whether the explanation is likely to be broadly urological or nephrological. Origins are most commonly simple or urological. Macroscopic bleeding is rare in renal disease, and urine colour is then usually more rather smoky than red except when there is very acute inflammation. The chief urological causes are neoplasia, infection, stones, and trauma. Some traditionally medical conditions may cause simple bleeding; examples include cystic kidney diseases, papillary necrosis and macro- or microvascular ischaemic lesions. The major concern to nephrologists is that even non-visible haematuria may be a pointer to inflammatory or destructive glomerular processes. The presence of casts or dysmorphic red cells is a pointer to glomerular disease; more important in clinical practice are the three other key markers of renal disease: proteinuria, renal impairment in the absence of urinary tract obstruction, and hypertension. In the general population, microscopic haematuria does associate with a long-term increased risk of end-stage renal failure, so after negative investigations, occasional long-term checks are indicated. The case for population screening for haematuria appears weak.
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Haugaa, Kristina H., Francesco Faletra, and João L. Cavalcante. Cardiac rhythm disorders. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198726012.003.0063.
Full textAbstract:
Cardiac rhythm disorders require diagnostic, prognostic, and guidance of therapeutic procedures by echocardiography. The most common sustained cardiac arrhythmia is atrial fibrillation (AF) leading to an increased risk for mortality, heart failure, and thromboembolic events. Echocardiography is performed to assess the aetiology of AF which most commonly is associated with diseases leading to enlarged atria. Furthermore, echocardiography is crucial to evaluate thromboembolic risk by assessing the morphology and function of the left atrial appendage among other parameters. Non-invasive imaging modalities including two-dimensional transthoracic (TTE) and transoesophageal echocardiography (TOE) with three-dimensional imaging are often indicated. Finally, TOE can help in the preprocedural planning and providing guidance for interventions such as pulmonary vein ablation and percutaneous left atrial appendage closure. In patients with ventricular arrhythmias, TTE is the first-line diagnostic tool for assessing the aetiology of ventricular arrhythmias. Ischaemic heart disease, either acute or chronic fibrosis, is the most common causes of ventricular tachycardias. Left ventricular ejection fraction remains the most important parameter for indication of an implantable cardioverter defibrillator for primary prevention therapy, although newer strain echocardiographic measures may add incremental prognostic information.
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Arntz, Hans-Richard. Sudden cardiac death: epidemiology and prevention. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0005.
Full textAbstract:
Even if sudden cardiac death is considered to be the most frequent cause of death in adults in industrialized countries, its incidence varies widely, depending on the definition and the source and quality of underlying data. It is estimated that about 70-80% of cases are due to coronary heart disease. The remaining 20% are attributable to a wide variety of inborn, genetically determined or acquired diseases, including a small group with hitherto undefined background. Prevention primarily encompasses the treatment of cardiovascular risk factors to avoid manifestations of coronary heart disease. Furthermore, preventive strategies are targeted to define groups of patients with an increased risk for sudden cardiac death or individuals at risk in specific populations, e.g. competitive athletes. A major target group are patients with impaired left ventricular function, preferentially due to myocardial infarction. These patients, and some less clearly defined patient groups with non-ischaemic cardiomyopathy and heart failure, may benefit from the insertion of an implantable cardioverter-defibrillator. With regard to pharmacological prevention, treatment of the underlying condition is the mainstay, since no antiarrhythmic substance-with the exemption of beta-blockers in some situations-has shown to be of efficacy.
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Neyrinck, Arne P., Patrick Ferdinande, Dirk Van Raemdonck, and Marc Van de Velde. Donor organ management. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0034.
Full textAbstract:
Organ transplantation is the standard treatment modality for end-stage organ disease in selected cases. Two types of potential organ donors can be identified: the brain-dead ‘heart-beating donors’, referred to as DBD (donation after brain death), and the warm ischaemic ‘non-heart-beating donors’, referred to as DCD (donation after circulatory death). Brain death induces several physiological changes in the DBD donor. An autonomic storm is characterized by massive catecholamine release, followed by autonomic depletion during a vasoplegic phase. This is associated with several hormonal changes (suppression of vasopressin, the hypothalamic-pituitary-adrenal axis, and the hypothalamic-pituitary-thyroid axis) and an inflammatory response. These physiological changes form the basis of organ donor management, including cardiovascular stabilization and hormonal therapy (including vasopressin and analogues, thyroid hormone, and cortisol). Donor management is the continuation of critical care, with a shift towards individual organ stabilization. An aggressive approach to maximize organ yield is recommended; however, many treatment strategies need further investigation in large randomized trials. DCD donors have now evolved as a valid alternative to increase the potential donor pool and challenge the clinician with new questions. Optimal donor comfort therapy and end-of-life care are important to minimize the agonal phase. A strict approach towards the determination of death, based on cardiorespiratory criteria, is prerequisite. Novel strategies have been developed, using ex situ organ perfusion as a tool, to evaluate and recondition donor organs. They might become more important in the future to further optimize organ quality.
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Pipitone, Nicolò, Annibale Versari, and Carlo Salvarani. Large-vessel vasculitis. Oxford University Press, 2013. http://dx.doi.org/10.1093/med/9780199642489.003.0133.
Full textAbstract:
Large-vessel vasculitis includes giant cell arteritis (GCA) and Takayasu's arteritis (TAK). GCA affects patients aged over 50, mainly of white European ethnicity. GCA occurs together with polymyalgia rheumatica (PMR) more frequently than expected by chance. In both conditions, females are affected two to three times more often than males. GCA mainly involves large- and medium-sized arteries, particularly the branches of the proximal aorta including the temporal arteries. Vasculitic involvement results in the typical manifestations of GCA including temporal headache, jaw claudication, and visual loss. A systemic inflammatory response and a marked response to glucocorticoids is characteristic of GCA. GCA usually remits within 6 months to 2 years from disease onset. However, some patients have a chronic-relapsing course and may require long-standing treatment. Mortality is not increased, but there is significant morbidity mainly related to chronic glucocorticoid use and cranial ischaemic events, especially visual loss. The diagnosis of GCA rests on the characteristic clinical features and raised inflammatory markers, but temporal artery biopsy remains the gold standard to support the clinical suspicion. Imaging techniques are also used to demonstrate large-vessel involvement in GCA. Glucocorticoids are the mainstay of treatment for GCA, but other therapeutic approaches have been proposed and novel ones are being developed. TAK mainly involves the aorta and its main branches. Women are particularly affected with a female:male ratio of 9:1. In most patients, age of onset is between 20 and 30 years. Early manifestations of TAK are non-specific and include constitutional and musculoskeletal symptoms. Later on, vascular complications become manifest. Most patients develop vessel stenoses, particularly in the branches of the aortic artery, leading to manifestations of vascular hypoperfusion. Aneurysms occur in a minority of cases. There are no specific laboratory tests to diagnose TAK, although most patients have raised inflammatory markers, therefore, imaging techniques are required to secure the diagnosis. Glucocorticoids are the mainstay of treatment of TAK. However, many patients have an insufficient response to glucocorticoids alone, or relapse when they are tapered or discontinued. Immunosuppressive agents and, in refractory cases, biological drugs can often attain disease control and prevent vascular complications. Revascularization procedures are required in patients with severe established stenoses or occlusions.
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Pipitone, Nicolò, Annibale Versari, and Carlo Salvarani. Large-vessel vasculitis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199642489.003.0133_update_003.
Full textAbstract:
Large-vessel vasculitis includes giant cell arteritis (GCA) and Takayasu’s arteritis (TAK). GCA affects patients aged over 50, mainly of white European ethnicity. GCA occurs together with polymyalgia rheumatica (PMR) more frequently than expected by chance. In both conditions, females are affected two to three times more often than males. GCA mainly involves large- and medium-sized arteries, particularly the branches of the proximal aorta including the temporal arteries. Vasculitic involvement results in the typical manifestations of GCA including temporal headache, jaw claudication, and visual loss. A systemic inflammatory response and a marked response to glucocorticoids is characteristic of GCA. GCA usually remits within 6 months to 2 years from disease onset. However, some patients have a chronic-relapsing course and may require longstanding treatment. Mortality is not increased, but there is significant morbidity mainly related to chronic glucocorticoid use and cranial ischaemic events, especially visual loss. The diagnosis of GCA rests on the characteristic clinical features and raised inflammatory markers, but temporal artery biopsy remains the gold standard to support the clinical suspicion. Imaging techniques are also used to demonstrate large-vessel involvement in GCA. Glucocorticoids are the mainstay of treatment for GCA, but other therapeutic approaches have been proposed and novel ones are being developed. TAK mainly involves the aorta and its main branches. Women are particularly affected with a female:male ratio of 9:1. In most patients, age of onset is between 20 and 30 years. Early manifestations of TAK are non-specific and include constitutional and musculoskeletal symptoms. Later on, vascular complications become manifest. Most patients develop vessel stenoses, particularly in the branches of the aortic artery, leading to manifestations of vascular hypoperfusion. Aneurysms occur in a minority of cases. There are no specific laboratory tests to diagnose TAK, although most patients have raised inflammatory markers, therefore, imaging techniques are required to secure the diagnosis. Glucocorticoids are the mainstay of treatment of TAK. However, many patients have an insufficient response to glucocorticoids alone, or relapse when they are tapered or discontinued. Immunosuppressive agents and, in refractory cases, biological drugs can often attain disease control and prevent vascular complications. Revascularization procedures are required in patients with severe established stenoses or occlusions.