Medicine Chest News - Part 5

Treatment of Chronic Symptomatic Supraventricular Bradyarrhythmias with Transdermal ScopolamineChronic persistent or intermittent symptomatic bradyar-rhythmias of sinus, atrial or atrioventricular (AV) junctional origin are customarily treated by implantation of a permanent cardiac pacemaker. The management of such arrhythmias can present a challenge in patients in whom permanent pacemaker implantation may not be indicated, such as in the demented or terminally ill. Repeated oral administration of atropine or sublingual administration of isoproterenol may reduce frequency or magnitude of supraventricular bradyarrhythmias, but these therapeutic modalities commonly produce unacceptable side effects and are not without risk. This report describes a demented patient whose supraventricular bradyarrhythmias substantially improved following the application of transdermal scopolamine. Read the rest of this entry »

This patient displayed several unusual features of sarcoidosis, namely: the large, bilateral pleural effusions, myocardial and pericardial involvement, lack of systemic “markers” for the disease process, and lack of response to steroids. It is estimated that approximately 1 percent of patients with sarcoidosis have pleural involvement. The presence of either bilateral or massive pleural effusions are usually the subjects of case reports. Sarcoidosis may affect any area of the heart—pericardium, myocardium, or endocardium. Of these, the myocardium is most frequently involved. The exact incidence of cardiac involvement, however, is difficult to ascertain. Autopsy series suggest an incidence between 20 and 30 percent, although these figures are probably quite high for all patients with sarcoidosis. Pericardial involvement, by contrast, is unusual. Only 31 cases of pericardial granulomas (usually diagnosed at necropsy) were identified by 1979. The frequency of small pericardial effusions (which may be due to disease affecting the pericardium or the epicardium) appears to be subject to the diligence of the search. Nineteen percent of 48 consecutive sarcoidosis patients in a series by Kinney et al had small pericardial effusions diagnosed by echocardiography. Thus, it is unclear how often and to what extent sarcoidosis may affect the heart. Read the rest of this entry »

Myocardial Sarcoidosis Unresponsive to SteroidsTreatment with Cyclophosphamide
Corticosteroids are the mainstay in the treatment of chronic sarcoidosis. Only recently have immune-alter-ing medications been used, usually in patients who have been shown to have disease unresponsive to steroid therapy. The following case exemplifies this unusual aspect of sarcoidosis.
Case Report
A 37-year-old black woman presented in January, 1979 with shortness of breath and bilateral hilar lymphodenopathy. Sarcoidosis was diagnosed by mediastinoscopy and biopsy. Prednisone was prescribed, but she discontinued its use after two months due to Cushingoid side effects. In August, 1979, she presented with a massive left pleural efiusion. An exhaustive workup revealed only sarcoidosis. Prednisone was started at 30 mg per day. The pleural efiusion initially resolved but gradually recurred. After eight months of steroid treatment consisting of at least 30 mg/day, a massive left and small right pleural efiusion were seen on the chest x-ray film. Cardiomegaly was also seen and an echocardiogram demonstrated gross pericardial efiusion. Therapy with high-dose prednisone (60-100 mg/day) was associated with an immediate reduction in the pleural and pericardial effusions. These findings later recurred and by August, 1980, the physical examination revealed anasarca. Read the rest of this entry »

The two patient populations best characterized for the purpose of comparing 24-hour arrhythmia prevalence are those patients postmyocardial infarction and patients with idiopathic dilated cardiomyopathy. In the postinfarction group, 15 to 25 percent have VPBs (^3/hour) and 10 to 15 percent have one or more runs of nonsustained ventricular tachycardia; whereas comparative prevalence rates in patients with symptomatic heart failure due to idiopathic dilated cardiomyopathy are higher (60 to 80 percent and 35 to 50 percent respectively). The prevalence of repetitive ventricular arrhythmias increases with more severe left ventricular dysfunction. In the present study, there was an analagous increase in repetitive VPBs in patients with edema, presumably those patients with more severe right ventricular dysfunction. Read the rest of this entry »

Asymptomatic Ventricular Arrhythmias in Patients with Obstructive Lung DiseaseShould They Be IVeated?
In this issue of Chest (see page 44) Shih and colleagues make important observations on the frequency and significance of cardiac arrhythmias during a 24-hour electrocardiographic (ECG) recording in a well-defined patient population with chronic obstructive lung disease. Previous studies have reported variable types, as well as a wide disparity of arrhythmia prevalence figures, in patients with obstructive lung disease. These discrepancies are partially explained by the differences in recording ECG duration, (12-lead ECG vs continuous ECG recording) severity of respiratory failure, (inpatient vs outpatient) and the frequency of concomitant organic heart disease (especially coronary artery disease). While previous observational studies have called attention to these arrhythmias, conclusions as to their importance are lacking due to the limitations described above. In contrast to the previous reports, the present study focused on a well-defined group of ambulatory patients selected from the Nocturnal Oxygen Therapy Trial Group, who were characterized by severe resting hypoxemia and hypercarbia, many of whom had right heart failure. This population would be a reasonable one in whom to consider prophylactic antiarrhythmia therapy if a clear indication (ie, increased mortality risk) could be demonstrated. Read the rest of this entry »

Postmortem examination showed marked pleural thickening and adhesion, especially on the left side. On the left side, there were dense adhesions between the aorta, pericardium, and mediastinal structures. A portion of the aorta and pericardium were excised with both lungs. Dissection showed a hole just beneath the brown vegetation on the lateral wall of the left main bronchus that opened into the aorta (Fig 1 and 2). A probe demonstrated a fistula between the left main bronchus and the aorta (Fig 3). Serial cuts through the fistula showed granulomas with caseous necrosis. Auramine-rhodamine stain of the specimen showed typical bacilli under the fluorescent microscope. Sections of both lungs showed anthracotic deposits and chronic inflammatory reactions with scattered granulomas, some with caseous necrosis. Auramine-rhodamine stain of these areas also showed acid-fast bacilli. The aorta was otherwise normal. Read the rest of this entry »

Broncho-aortic Fistula Secondary to Pulmonary TuberculosisMassive hemoptysis, defined as expectoration of more than 500 ml of blood within 24 hours, is usually due to tuberculosis, bronchiectasis, or pulmonary abscess. Investigation of these cases include a routine chest x-ray film, bronchoscopy, bronchography, sputum cytology, angiographic techniques, and, recently, computerized axial tomographic scanning. Fistulous connection between the tracheobronchial tree and the aorta occurs very rarely and has been reported secondary to aortic aneurysmal or graft erosion of the tracheobronchial wall. We report a case of broncho-aortic fistula secondary to pulmonary tuberculosis without primary involvement of the aorta. Read the rest of this entry »

Although right ventricular infarction has been described for many years at autopsy, the hemodynamic impact was not well recognized until the report of Cohn et al in 1974. Since it is essential to recognize early signs of predominant right ventricular infarction because it may require a unique form of therapy, several clinical and electrocardiographic studies have attempted to detect right ventricular involvement in acute myocardial infarction. Necrosis of a large proportion of the right ventricle causes a hemodynamic derangement characterized by systemic hypotension and disproportionate elevation of right ventricular filling pressure compared to left ventricular filling pressure. This in turn causes an elevation of the central venous pressure (jugular venous pressure), one of the hallmarks of the bedside diagnosis of right ventricular infarction. Read the rest of this entry »



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