Self-Reported Results of Cutaneous Lupus about Quality associated with Life

Prevalence regarding self-report photosensitivity throughout cutaneous lupus erythematosus.

Journal Am. Acad. Dermatol. 2011 July 8

What is a topic?

Ultraviolet radiation from the sun can certainly worsen signs and symptoms of cutaneous lupus (CLE). “Photosensitivity” describes a range of reactions to be able to sun subjection in CLE individuals and, accordingly, CLE patients may perhaps be described as being approximately “photosensitive” or nada. However, the announced prevalence connected with photosensitivity involving CLE sufferers varies widely because of many factors linked to its dimension.

What would the experts hope to find out?

The analysts hoped to read the frequency of self-reported photosensitivity among individuals with lupus, as nicely as it's effects about quality associated with life. The research workers also attempt to determine if clinical appointment questions can successfully identify CLE patients experiencing photosensitivity and possibly pass on the solutions to lupus-specific dermis disease action and quality of life.

Who appeared to be studied?

The scientists studied 169 people who have CLE becoming treated in the Medical Dermatology Clinic of the University regarding Pennsylvania College of Medicine. All contributors were at the very least 18 years of age and acquired some evidence of CLE as well as systemic lupus having skin manifestations.

How ended up being the analyze conducted?

After a visit to the clinic pertaining to study enrollment, participants saw the clinic thereafter if the patient suffered a adjust in signs, had some sort of change throughout medication, of if it absolutely was over per annum since the last study see. Information related to participants ended up being gathered via examination of patient story, medical documents, as effectively as by questionnaires as well as a physical examination. Assessments with severity of CLE illness activity in addition to damage were created by technique CLE Sickness Area plus Severity Listing (CLASI), a validated tool helpful in assessing CLE severeness. The impression of CLE manifestations with patient level of quality of existence (seeing that measured simply by skin disease effects upon functioning, symptoms, and behavior) was assessed by use of the Skindex-29, a checked measure with skin-specific quality of living.

Participants was also expected about cigarette smoking and sunrays exposure, lupus signs, additional autoimmune diseases (aside from lupus), as nicely as prescription medication effectiveness and side effects. In improvement, participants had been asked in relation to their story of photosensitivity, frequency people of sunrays protection, and progress of lupus lesions inside sun-exposed spots. Based about patient responses about their particular history connected with photosensitivity, patients was classified into on the list of following groupings: “photosensitive collection, ” “photosensitive-suggestive group, ” and also “non-photosensitive party. ”

What have the researchers find?

Of your 169 lupus persons that was, 80% have been women, 66% was Caucasian, 28% ended up African-America, 5% was Asian, and 1% was Hispanic. Also, 46% got discoid lupus (DLE), 25% acquired sub-acute cutaneous lupus (SCLE), and others had one of many additional types of CLE like tumid lupus, acute CLE, chronic cutaneous CLE, or non-specific CLE (lower than 10% per).

Overall, about 68% with participants documented symptoms regarding photosensitivity though only 24% dissmissed off experiencing virtually any photosensitivity. More compared to half of participants obtaining different types of CLE (besides DLE as well as chronic cutaneous CLE) documented both your history of and current photosensitivity. Based about these effects, 91 contributors were contained in the photosensitive group. The photosensitive-suggestive party included 5 participants as you move non-photosensitive team included 40 participants.

When patients while in the photosensitive team were in comparison with those inside non-photosensitive team, the past developed lesions throughout sun-exposed areas usually and far more frequently employed in sun-protective behavior versus latter. Also, patients in the photosensitive team had greater lupus-specific cutaneous ailment activity (seeing that measured by simply CLASI), tended to stress more regarding sun subjection, and indicated that their particular skin sickness affected the outdoor task behavior to somewhat of a greater amount than patients within the non-photosensitive class. Furthermore, patients in the photosensitive class were more relying on their dermis disease within the areas regarding functioning, symptoms, and inner thoughts than had been patients while in the non-photosensitive class.

Importantly, even inside photosensitive team, it was possible to identify sub-groups in which experienced differing degrees of impairments within quality connected with life (seeing that indicated simply by skin ailment effects on functioning, symptoms, and emotional baggage) depending on their level of photosensitivity. Participants with higher photosensitivity had greater impairments within quality associated with life (while indicated through skin disorder effects upon functioning, symptoms, and inner thoughts) as compared with did objectives with decrease photosensitivity.

What have been the limitations in the study?

The participants built into this analysis were going to a referral-only core, which could possibly have increased the possibility that these people had worse skin disorder than those and also require been viewing a common dermatologist. Also, this study couldn't determine the causal marriage between photosensitivity plus skin disease or quality of lifetime.

What do the effects means available for you?

The effects indicate that will clinical appointment questions can certainly identify CLE sufferers with photosensitivity. Photosensitivity is definitely common in CLE sufferers, who could experience inable quality connected with life with regard to daily working, symptoms, and behavior - sometimes independently of CLE illness activity. Compliance together with recommendations in avoiding UV mild exposure continues to be warranted given the connections with exacerbation with skin disease along with other lupus clinical manifestations.

Lupus Symptoms in Women

Lupus is usually an uncommon, complex plus improperly perceived situation that will impacts numerous portions of the entire body plus brings about many different signs including mild to help life-threatening. Most of the sufferers of lupus symptoms are women in their 20's. Lupus is usually an autoimmune disease, which means that it is attributable to difficulty the health (the body’s organic support alongside illness plus contamination). Quite a few popular signs associated with lupus incorporate:

• fatigue
• skin rash
• joint discomfort plus puffiness
• and photosensitivity

Varieties of lupus

There are certain varieties of lupus. The key kinds will be:

•discoid lupus erythematosus

•drug-induced lupus

•systemic lupus erythematosus

How often is lupus?

Lipus is usually an uncommon situation, along with 90% associated with symptoms happening in women. A lot of situations associated with SLE earliest start out in women who're associated with childbearing era (between the age range associated with fifteen to fifty).

There are actually noticeable distinctions within the way popular Lupus will be amongst different cultural communities. By way of example, in the united kingdom:

•one within just about every 5,000 white women will likely get SLE

•one within just about every 1,000 women associated with Chinese beginning will likely get SLE

•one within just about every 625 Afro-Caribbean women will likely get SLE

There exists at present absolutely no solution pertaining to SLE, nonetheless there are actually an array of different medications that will can help to ease a lot of the symptoms of lupus.

Lupus Symptoms in Women

Expecting mother along with symptoms associated with lupus might possibly deal with certain signs which include rashes plus lupus size which sometimes seem due to an increased blood flow in the skin color, increase associated with brand-new curly hair while in carrying a child and also extreme hairloss after the the baby born. Numerous gurus have got mentioned that will women who have lupus symptoms cannot come to be expecting because of their situation. Nonetheless, that myth may be refused by simply gurus, something like 50% associated with expecting mother that has lupus symptoms can offer the normal carrying a child plus good beginning healthful infants. Conversely, quite a few females might maybe deal with problems and in many cases lose the fetuses in the carrying a child.

On the list of stuff all of us really need to discover is 20% associated with lupus patients who're expecting often have got the abrupt surge within BP (blood pressure), protein in the urine, a disorder which in turn you’ll locate called Preeclampsia or toxaemia plus amount of considerable therapy in addition to instant supply. The presence of antibody identified as anti-phospholipid antibody could possibly occur to help lupus pregnancies that's yet another considerable problems. In a great many situations, women that has extreme type of lupus symptoms within pregnancy have to get by way of a caesarian section to help reduce the use of the early the baby.

There are a few golden rules being then expecting women living with lupus, they are: often outings on the doctor, good hsv associated with relief medication, stay away from tablets that could put the baby’s life in danger, the healthy food eating routine, in addition to absolutely no awful routines similar to cigarette smoking or having. In the end, an average carrying a child may be carried on by simply expecting mother that endured lupus symptoms whenever they stick to the correct supervision and possess the equalize normal associated with living. Furthermore, it is looked at that most medications pertaining to Systemic Lupus Erythematosus will be safe and sound being utilised in the carrying a child considering the fact that they don’t pass through the placenta. Read more articles about Lupus Symptoms in Women.

Do Acid Reflux Drugs and Antacids Really Work?

Sooner or later you knew it was going to happen. Eventually you just had to admit everything you've tried has failed to cure your acid reflux. But don't blame yourself; it's not your fault.

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TOP 1 Oli Sintetik Mobil-Motor Indonesia

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Autoimmune Hemolytic Anemia (AIHA) - symptoms of anemia

Anemia and autoimmune disease What is?Anemia is the result of variations in blood hemoglobin decreased. Autoimmune process (the process of attacking its own immune system cells), one of which is anemia caused by various reasons. Hemoglobin, anemia before and had dropped, and red blood cells as a result of the autoimmune process vulnerable.
Do you experience the process like?AIHA (autoimmune hemolytic anemia), the onset of symptoms of anemia, red blood cells as a result of the immune system itself is broken or a decrease of hemoglobin. As a result of being attacked by its own immune system to detect red blood cells as foreign cells and normal red blood cells mistakenly (analysis) will be cut and damaged. AIHA most unexplained. That warm-type AIHA AIHA (warm type AIHA) AIHA and cold type (cold type AIHA) of two types.
How the symptoms of AIHA?Most patients with AIHA, the last light level, in particular the destruction of red blood cells, has no symptoms. However, if the process is fast and heavy, then (mild jaundice), anemia and there will be yellow. This process continues for several months - a few months of the spleen, leading to larger and discomfort in the stomach full.
AIHA can be cured like?The action has not been treating the symptoms of mild AIHA when the symptoms when you need to corticosteroid therapy in order to attenuate the immune system, antibodies produced by the body and looks very realistic. If treatment is successful, the spleen to destroy red blood cells can reduce the number of (splenectomy) will be taking. And distributes the hit to the immune system antibodies that can not eat properly and mute output both when these doctors.
Check to find What is AIHA?
The required inspection and testing of diagnostic testing to monitor disease AIHA progresivitas. AIHA examination of suspicion toward physicians, complete blood tests, retikulosit total (red blood cells, immature imatur /), and the percentage of blood and urine bilirubin. Inspection AIHA, namely Tesutokumu (direct Coomb test), but you can verify that the testing of antibodies to red blood cells. Tests to monitor the success of treatment, blood tests are completed and the total proportion of bilirubin retikulosit.

Heart failure guidelines : strategies for implementation

A 50-year-old man is evaluated during a routine follow-up office visit for heart failure, which was diagnosed 1 year ago. A stress test at the time of diagnosis was negative for ischemia. At his most recent evaluation 4 months ago, an echocardiogram showed left ventricular enlargement and hypertrophy, a left ventricular ejection fraction of 40%, and no significant valvular disease. An electrocardiogram was unchanged, showing left ventricular hypertrophy but no evidence of previous myocardial infarction. The patient is currently asymptomatic, and his medications are hydrochlorothiazide and lisinopril.

On physical examination, heart rate is 85/min and blood pressure is 135/85 mm Hg. There is no jugular venous distention or peripheral edema. The lungs are clear. There is a soft S4 but no murmur.

Which of the following medications should be added to the patient's regimen?
A Carvedilol
B Digoxin
C Diltiazem
D Losartan
E Spironolactone

Key Points
* An angiotensin-converting enzyme inhibitor and a β-blocker are indicated in all patients with systolic heart failure, including asymptomatic patients with low ejection fractions.
* Spironolactone and digoxin are not indicated in patients with asymptomatic systolic heart failure.

Answer and Critique (Correct Answer = A)

Treatment with an angiotensin-converting enzyme (ACE) inhibitor and a β-blocker is indicated for all patients with any degree of systolic heart failure, including this asymptomatic patient with a low ejection fraction, because treatment with both agents has been shown to reduce morbidity and mortality.

Losartan, an angiotensin-receptor blocker (ARB), is an acceptable alternative in a patient who cannot tolerate an ACE inhibitor, but there is no benefit to adding an ARB to an ACE inhibitor. Calcium-channel blockers are indicated in patients with heart failure who have hypertension or angina that is not adequately controlled with an ACE inhibitor or β-blocker. First-generation calcium-channel blockers, such as nifedipine, diltiazem, and verapamil, cause a reactive increase in sympathetic activity in response to peripheral vasodilatation and negative inotropic effects, whereas second-generation calcium-channel blockers, such as amlodipine, are more vasoselective, less cardiodepressant, and do not appear to have a deleterious effect on outcome in patients with heart failure. Spironolactone and digoxin are not indicated for patients with asymptomatic systolic heart failure. Spironolactone reduces mortality in patients with severe symptomatic heart failure (New York Heart Association class III or IV) and a left ventricular ejection fraction ≤35%. Digoxin alleviates symptoms and reduces hospitalizations related to heart failure, but has not been shown to reduce mortality.
Bibliography

1. O’Connor CM. The new heart failure guidelines: strategies for implementation. Am Heart J. 2007;153:2-5. [PMID: 17394896]

Systolic Heart Failure

A 58-year-old man is evaluated in the office for a 3-month history of shortness of breath with exertion. He has a 10-year history of hypertension and type 2 diabetes mellitus but no history of coronary artery disease. His medications are extended-release metoprolol, aspirin, metformin, and atorvastatin.

On physical examination, blood pressure is 165/92 mm Hg and heart rate is 88/min. Jugular venous pressure is 10 cm H2O. Bibasilar crackles are present, cardiac rhythm is regular, and an S3 is present. Electrocardiogram shows normal sinus rhythm and left ventricular hypertrophy. Laboratory test results include potassium of 4.2 meq/L and creatinine of 1.0 mg/dL. An echocardiogram is ordered, and furosemide is prescribed.

The patient returns the following week with resolution of his symptoms. His blood pressure at this visit is 130/78 mm Hg, his heart rate is 65/min, jugular venous pressure is 4 cm H2O, lungs are clear, and the S3 is absent. The echocardiogram shows left ventricular hypertrophy, reduced systolic function, and inferior wall hypokinesis.

Which of the following is the most appropriate medication change at this time?
A Change metoprolol to carvedilol
B Start digoxin
C Start lisinopril
D Start spironolactone

Key Point
Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of ejection fraction or functional status, barring contraindications.

Answer and Critique (Correct Answer = C)

Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of the level of the ejection fraction or functional status unless there are contraindications (including hyperkalemia, acute renal failure, or a history of angioedema).

Sustained-release metoprolol and carvedilol are both approved for heart failure treatment in the United States. Currently, there is no definitive evidence indicating whether one is better than the other for the treatment of heart failure. Digoxin improves symptoms and reduces hospitalizations for patients with heart failure but is not indicated for patients with asymptomatic heart failure in the absence of other indications (such as rate control for atrial fibrillation). Spironolactone is indicated for patients with heart failure who have severe symptoms (New York Heart Association class III or IV).
Bibliography

1. Dagenais GR, Pogue J, Fox K, Simoons ML, Yusuf S. Angiotensin-converting-enzyme inhibitors in stable vascular disease without left ventricular systolic dysfunction or heart failure: a combined analysis of three trials. Lancet. 2006;368:581-8. [PMID: 16905022]

Acute Myocarditis

A 26-year-old woman is hospitalized because of a 7-day history of increasing shortness of breath. Two weeks ago, she had flu-like symptoms of fever, muscle aches, and chest pain, which have since resolved. She does not take any medications.

On physical examination, temperature is 37 °C (98.6 °F), blood pressure is 120/79 mm Hg, and heart rate is 100/min and regular. The lungs are clear. Cardiac examination shows a normal S1 and S2. Echocardiogram shows normal-sized ventricles, decreased systolic function (left ventricular ejection fraction, 40%) that is global and most severe in the anterior wall, and no significant valvular abnormalities. Coronary angiography discloses no evidence of coronary artery disease.

Which of the following is the most appropriate next step in treating this patient?
A Azithromycin
B Enoxaparin
C Ibuprofen
D Lisinopril
E Prednison

Key Point
Therapy for acute myocarditis generally consists of standard care for heart failure tailored to the severity of the myocarditis.

Answer and Critique (Correct Answer = D)

This patient's presentation, including a viral prodrome, chest pain, symptoms and findings of heart failure in the absence of significant coronary artery disease, is consistent with acute myocarditis, which can range in presentation from asymptomatic to acute cardiogenic shock. Wall motion abnormalities on echocardiography can be regional or global during acute myocarditis. There is no specific treatment for acute myocarditis other than supportive care and the usual treatment for heart failure, including an angiotensin-converting enzyme inhibitor such as lisinopril, in the absence of contraindications.

The patient's normal blood pressure is not consistent with a serious infection, such as sepsis, and in the absence of other, more concrete evidence for infection, antibiotics are not indicated. The results of the coronary angiography rule out acute coronary syndrome, and therefore enoxaparin is not indicated. Although myocarditis is characterized by inflammation, there is no proven role for ibuprofen or corticosteroids for treatment.
Bibliography

1. Magnani JW, Dec GW. Myocarditis: current trends in diagnosis and treatment. Circulation. 2006;113:876-90. [PMID: 16476862]

Heart Failure

A 68-year-old woman is hospitalized with palpitations and shortness of breath. She has a history of hypertension and chronic atrial fibrillation, and her medications are furosemide, candesartan, and warfarin. On physical examination, the heart rate is 120/min with an irregularly irregular rhythm, and blood pressure is 130/80 mm Hg with no evidence of pulsus paradoxus. She has an elevated jugular venous pressure with normal x and y descent, crackles in both lungs, and marked lower extremity edema. Echocardiography shows left ventricular hypertrophy, an ejection fraction of 70%, and no significant valvular disease.

After intravenous diuretics are begun, the patient's symptoms improve, and the crackles and peripheral edema resolve. Her heart rate is now 99/min, and her blood pressure is 120/75 mm Hg.

Which of the following is the most likely primary mechanism of her heart failure?
A Constrictive pericarditis
B Diastolic dysfunction
C Systolic dysfunction
D Valvular disease

Key Point
The diagnosis of diastolic heart failure is generally made when signs and symptoms of systolic heart failure are present but the echocardiogram shows a normal left ventricular ejection fraction and an absence of significant valvular abnormalities.

Answer and Critique (Correct Answer = B)

This patient has a history and echocardiographic findings consistent with diastolic dysfunction. She has hypertension, which predisposes to the development of left ventricular hypertrophy and associated impaired ventricular relaxation.

Although she presented with evidence of heart failure, the echocardiogram demonstrated normal systolic function and no significant valvular abnormalities that could account for the heart failure. Therefore, systolic dysfunction and valvular disease are unlikely. Constrictive pericarditis is also unlikely in the absence of pulsus paradoxus, normal x and y descent, and no echocardiographic evidence of constrictive pericarditis, such as pericardial thickening or abrupt posterior motion of the ventricular septum in early diastole with inspiration.

The primary treatment goals in patients with diastolic heart failure are to treat the underlying cause (if possible), manage any potentially exacerbating factors, and optimize diastolic filling by slowing the heart rate with β-blockers. To date, there have been no medications shown to reduce morbidity and mortality in patients with diastolic dysfunction.
Bibliography

1. Chinnaiyan KM, Alexander D, Maddens M, McCullough PA. Curriculum in cardiology: integrated diagnosis and management of diastolic heart failure. Am Heart J. 2007;153:189-200. [PMID: 17239676]

Cardiomyopathy

A 38-year-old man is hospitalized with palpitations and dyspnea. He has no significant medical history and does not take any medications. He has a 20-pack-year smoking history and drinks alcohol daily. He does not use illicit drugs.

On physical examination, temperature is 36.9 °C (98.5 °F), blood pressure is 120/80 mm Hg, and heart rate is 115/min. Jugular venous pressure is normal. The lungs are clear. Cardiac examination shows an irregularly irregular rhythm. There is trace edema at both ankles.

Laboratory Studies
Hemoglobin 14 g/dL
Mean corpuscular volume 101 fL
Aspartate aminotransferase 55 U/L
Alanine aminotransferase 45 U/L
Thyroid-stimulating hormone 4.5 μU/mL

Electrocardiogram shows normal voltage, normal axis, and atrial fibrillation. Echocardiogram shows dilated ventricles with normal wall thickness and severely decreased systolic function (left ventricular ejection fraction, 15%). The patient is started on lisinopril, carvedilol, and warfarin. Later in the hospital course, he spontaneously converts to normal sinus rhythm, he feels well, and has a blood pressure of 105/75 mm Hg and a heart rate of 63/min. Electrocardiogram confirms normal sinus rhythm.

Which of the following is the most likely type of cardiomyopathy in this patient?
A Alcoholic
B Amyloid
C Hypertrophic
D Ischemic

Key Point
Alcoholic cardiomyopathy is a dilated cardiomyopathy.

Answer and Critique (Correct Answer = A)

This patient likely has alcoholic cardiomyopathy, which generally occurs after many years of heavy alcohol consumption, although it may also occur after a short period of heavy consumption. Typically, both ventricles are dilated and globally hypokinetic. The patient reports that he drinks alcohol daily, and his laboratory test results suggest chronic alcohol use (macrocytosis) and possibly an acute episode of heavy alcohol use (mild elevation of aminotransferases, new-onset atrial fibrillation). In addition to medical therapy for heart failure, therapy for alcoholic cardiomyopathy must include total abstinence from alcohol. Abstinence may reverse the cardiomyopathy in patients with less advanced disease.

Cardiac amyloidosis results in increased left ventricular wall thickness due to deposition of amyloid, and, as a result, typically presents with restrictive cardiomyopathy, which is characterized by diastolic rather than systolic dysfunction. On echocardiography, ventricular chambers are typically small with thick walls, and the atria are dilated. Because increased left ventricular wall thickness is caused by infiltration of the myocardium rather than hypertrophy, the electrocardiographic voltage is generally low.

Hypertrophic cardiomyopathy is characterized by inappropriate, marked, and asymmetric hypertrophy of the left ventricle. The hypertrophy usually involves the interventricular septum, although there is a wide range of severity and location of hypertrophy, hemodynamic consequences, and symptoms. The left ventricular cavity is small, unlike the cavity in this patient.

Ischemic cardiomyopathy is often, but not invariably, associated with symptomatic coronary artery disease. The electrocardiogram may show evidence of previous infarction and the echocardiogram typically shows focal, not global, hypokinesis.
Bibliography

1. Piano MR. Alcoholic cardiomyopathy: incidence, clinical characteristics, and pathophysiology. Chest. 2002;121:1638-50. [PMID: 12006456]

Premature Ventricular Contractions

A 33-year-old man is evaluated in the office for palpitations. He reports intermittent symptoms that do not correlate with any particular activity. He is only mildly disturbed by the palpitations but wants to have his heart evaluated. His medical history is unremarkable, and he takes no medications. His physical examination and electrocardiogram also are unremarkable. A 24-hour electrocardiogram shows a normal sinus rhythm with 3004 total premature ventricular contractions in 24 hours. An echocardiogram shows a structurally normal heart. Thyroid function studies and electrolyte levels are normal.

Which of the following is the most appropriate treatment for this patient?
A Atenolol
B Flecainide
C Radiocatheter ablation
D Reassurance

Key Point
In healthy adults, premature ventricular contractions are common and are not a cause for concern.

Answer and Critique (Correct Answer = D)

n healthy adults, premature ventricular contractions at rest are common and are not a cause for concern. Even very frequent premature ventricular contractions on a 24-hour electrocardiogram are not of concern in the absence of underlying structural heart disease. This otherwise healthy patient needs reassurance. Suppression of premature ventricular contractions is indicated only in patients with severe and disabling symptoms, which may include palpitations, fatigue, and lightheadedness. In these patients, β-blockers are the safest initial choice. Antiarrhythmic agents such as flecainide are associated with more side effects and thus are a second-line option for patients who continue to have debilitating symptoms despite β-blocker therapy. Catheter ablation of premature ventricular contractions is feasible; however, because of the technical demands of the procedure and its variable success rate, it is reserved for the most refractory cases.
Bibliography

1. Ng GA. Treating patients with ventricular ectopic beats. Heart. 2006;92:1707-12. [PMID: 17041126]

Asymptomatic Atrial Fibrillation

A 56-year-old man is evaluated in the office during a routine physical examination. He has no cardiovascular complaints. His medical history is unremarkable.

On physical examination, heart rate is approximately 90/min and irregularly irregular, and blood pressure is 130/78 mm Hg. Except for the abnormal cardiac rhythm, the remainder of the examination is unremarkable.

The electrocardiogram demonstrates atrial fibrillation with a heart rate of 92/min. The chest radiograph is unremarkable. Laboratory test results, including assessment of thyroid function, are normal. The patient is not aware of the abnormal rhythm or its duration.

In addition to heart rate control, which of the following would be most appropriate for this patient?
A Aspirin
B Clopidogrel
C Direct-current cardioversion
D Warfarin

Key Point
Aspirin is sufficient thromboembolic risk protection in patients with asymptomatic atrial fibrillation and no risk factors for stroke.

Answer and Critique (Correct Answer = A)

This patient with asymptomatic atrial fibrillation has no risk factors for stroke; therefore, aspirin would be sufficient thromboembolic risk protection. The CHADS2 score is used to assess stroke risk in patients with atrial fibrillation. The CHADS2 score assigns 1 point each for the presence of congestive heart failure, hypertension, age 75 years or older, and diabetes mellitus and 2 points for a history of stroke or transient ischemic attack. This patient's CHADS2 score is 0; therefore, risk of stroke is low and anticoagulation other than aspirin is not necessary.

Cardioversion is recommended primarily for patients with symptoms related to atrial fibrillation or patients with hemodynamic deterioration due to the loss of sinus rhythm. There are no data to suggest that conversion to sinus rhythm improves survival; cardioversion is therefore not indicated in this patient. If the patient's symptoms progressed to a point at which cardioversion would be indicated, anticoagulation with warfarin would be required first because of the potential of having an atrial clot that could embolize upon the restoration of sinus rhythm. Clopidogrel has not been demonstrated to be effective thromboprophylaxis for patients with atrial fibrillation. The combination of clopidogrel and aspirin has been shown to worsen outcomes in patients with atrial fibrillation by increasing the risk of bleeding.
Bibliography

1. Go AS, Fang MC, Singer DE. Antithrombotic therapy for stroke prevention in atrial fibrillation. Prog Cardiovasc Dis. 2005;48:108-24. [PMID: 16253651]

Atrial Fibrilation

A 78-year-old man is evaluated in the emergency department for a 1-week history of palpitations and weakness. He has had multiple similar episodes in the past year but has never sought treatment. His other medical problems include hypertension and type 2 diabetes mellitus, and his medications are lisinopril, hydrochlorothiazide, and metformin. He has no history of heart disease and had a normal electrocardiographic exercise stress test 1 year ago.

On physical examination, he is alert and in no acute distress. Blood pressure is 135/80 mm Hg, heart rate is 143/min and irregular, respiration rate is 14/min, and oxygen saturation is 98% with the patient breathing room air. On cardiac examination, there are no murmurs. Lungs are clear.

Electrocardiogram shows atrial fibrillation with a rapid ventricular rate without evidence of ischemic changes. Cardiac enzyme values are normal. His heart rate decreases to 74/min with administration of labetalol.

Which of the following is the most appropriate long-term treatment for this patient?

	A Atrioventricular nodal ablation and pacemaker implantation
	B Metoprolol and aspirin
	C Metoprolol and warfarin
	D Procainamide

Key Points

• Strategies of rate versus rhythm control for atrial fibrillation are similar with respect to symptoms, mortality, and stroke risk.
• Most patients with atrial fibrillation are treated with a combination of rate control and long-term anticoagulation.

Answer and Critique (Correct Answer = C)

This patient is best treated with rate control and anticoagulation. Atrial fibrillation is the most common clinically significant arrhythmia and accounts for the most hospitalizations for cardiac arrhythmias. It occurs in less than 1% of patients ages 60 to 65 years but in 8% to 10% of patients older than 80 years. The estimated risk for stroke in affected patients is 5% per year without anticoagulation. In patients with nonvalvular atrial fibrillation, warfarin with a target INR of 2.0 to 3.0 has been shown to decrease stroke risk by an average of 62%, compared with a 19% decrease with aspirin therapy. To determine whether the risk of stroke is high enough to warrant chronic anticoagulation, risk stratification scores have been developed. One such stratification scheme is known as CHADS₂ score: Congestive heart failure, Hypertension, Age >75 years, Diabetes, Stroke or transient ischemic attack (TIA). Patients are given 2 points for a history of stroke or TIA (the strongest risk factor) and 1 point for all other risk factors. This patient has a CHADS₂ score of 3. The risk of stroke is lowest in patients with a CHADS₂ score of 0 (1.2%). The risk is 18% for a CHADS₂ score of 6 (maximum score). Patients with a CHADS₂ score of ≥3 and patients with a history of stroke are at high risk and should be considered for chronic anticoagulation with warfarin. Patients with a CHADS₂ score of 1 or 2 should be assessed on an individual basis for aspirin versus warfarin therapy.

In patients who tolerate atrial fibrillation with few symptoms, restoration of normal sinus rhythm is not indicated. Strategies of rate versus rhythm control have been found to be similar with respect to symptoms, mortality, and stroke risk. More hospitalizations and adverse drug reactions occur in patients receiving rhythm control compared with rate control. This elderly patient would be at significant risk of drug side effects from anti-arrhythmic agents and would likely have breakthrough episodes of atrial fibrillation. Therefore, in addition to chronic anticoagulation with warfarin, this patient should receive medication to control the ventricular rate, such as a β-blocker.

Atrioventricular nodal ablation for atrial fibrillation with pacemaker placement should be reserved for those patients who do not tolerate pharmacologic therapy. New ablation strategies are being investigated and are increasingly recommended in clinical practice guidelines. These include catheter-directed ablation of the pulmonary vein ostia within the left atrium. The success rate of this procedure is as high as 88% at 6 months without requiring pacemaker placement.

Bibliography

1. Snow V, Weiss KB, LeFevre M, McNamara R, Bass E, Green LA, Michl K, Owens DK, Susman J, Allen DI, Mottur-Pilson C; AAFP Panel on Atrial Fibrillation; ACP Panel on Atrial Fibrillation. Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med. 2003;139:1009-17. [PMID: 14678921]
2. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864-70. [PMID: 11401607]

Acute Coronary Syndrome

A 49-year-old man is evaluated in the emergency department for chest discomfort accompanied by nausea and dyspnea that began 2 hours ago. On physical examination, blood pressure is 109/78 mm Hg and heart rate is 88/min. There is no jugular venous distention and no carotid bruits. The lungs are clear. Cardiac examination shows a normal S1 and S2 and no gallops, rubs, or murmurs. The troponin level is 6 ng/mL (normal <0.5 ng/mL). Electrocardiogram shows a 1-mV ST elevation in leads II, III, and aVF.

He is treated with enoxaparin, aspirin, metoprolol, and glycoprotein receptor blockers and is taken to the cardiac catheterization laboratory. A stent is placed in a subtotally occluded right coronary artery. A follow-up echocardiogram shows normal wall motion, normal valve function, and a normal ejection fraction. By day 4, he has no complications and is prepared to be discharged.

In addition to aspirin, clopidogrel, and metoprolol, which of the following medications should be given at discharge?
A Atorvastatin
B Gemfibrozil
C Niacin
D Warfarin

Key Point
In patients with an acute coronary syndrome, statin therapy is indicated regardless of the serum cholesterol level.

Answer and Critique (Correct Answer = A)

This patient has survived a small inferior wall myocardial infarction and was successfully treated with a stent. At discharge, he should receive aspirin, metoprolol, clopidogrel for at least 180 days, and a statin regardless of his serum cholesterol level. In patients with coronary artery disease, especially those presenting with symptoms and those undergoing revascularization by either stenting or bypass graft surgery, statin therapy reduces late cardiovascular events despite having minimal or no effect on the angiographic appearance of the coronary arteries.

The PROVE IT-TIMI 22 study compared a moderate-dose statin (pravastatin, 40 mg/d) with a high-dose statin (atorvastatin, 80 mg/d) in patients hospitalized for acute coronary syndrome. The median LDL cholesterol levels achieved were 95 mg/dL by the pravastatin group and 62 mg/dL for the atorvastatin group. Those receiving atorvastatin had a 16% reduction in the composite endpoint of death from any cause, myocardial infarction, unstable angina requiring rehospitalization, coronary artery revascularization, and stroke during 2 years of follow-up. These results showed evidence of benefit from early aggressive LDL cholesterol lowering with high-dose atorvastatin.

Warfarin is not indicated after ST-elevation myocardial infarction treated by stenting unless there is another indication such as atrial fibrillation, deep venous thrombosis, or intracardiac thrombus.

Niacin for hypertriglyceridemia may be needed, but at this time the triglyceride values are not reported and may be falsely elevated early in the course of ST-elevation myocardial infarction. The first line of treatment would be statins even for normal LDL cholesterol levels in patients with documented coronary artery disease. The combination of statins with a fibrate (e.g., gemfibrozil) is attractive for patients who have both high cholesterol and triglyceride levels or for those who continue to have elevated triglyceride levels after reaching their LDL cholesterol target on statin therapy. However, in this patient, the best initial choice is a statin.
Bibliography

1. Ray KK, Cannon CP, Ganz P. Beyond lipid lowering: What have we learned about the benefits of statins from the acute coronary syndromes trials? Am J Cardiol. 2006;98:18P-25P. Epub 2006 Sep 29. [PMID: 17126675]

Acute Inferior ST-elevation Myocardial Infarction

A 64-year-old woman is evaluated in the emergency department 6 hours after the onset of severe crushing chest pain associated with diaphoresis, nausea, and vomiting. Her medical history is significant only for hyperlipidemia; her medications are atorvastatin and aspirin. On physical examination, blood pressure is 140/88 mm Hg, and heart rate is 88/min. The lungs are clear, and no cardiac murmurs are heard. Examination of the abdomen and extremities is normal. Electrocardiogram shows a 3-mV ST elevation in leads II, III, and aVF, with occasional premature ventricular contractions. The hospital does not have cardiac catheterization facilities, and the patient is therefore given fibrinolytic therapy. Her chest pain resolves; she has two episodes of 6- to 10-beat ventricular tachycardia and stable hemodynamic parameters. Electrocardiogram now shows <0.5-mV ST elevation.

In addition to heparin and aspirin, which of the following approaches is the most appropriate next step in the management of this patient?
A Amiodarone
B β-Blocker
C Coronary angiography
D Lidocaine

Key Point
β-Blocker therapy reduces infarct size and the frequency of recurrent myocardial ischemia and improves short- and long-term survival.

Answer and Critique (Correct Answer = B)

This patient has features of successful reperfusion after an acute inferior ST-elevation myocardial infarction and may be treated medically until risk stratification is performed or recurrent ischemia or complications occur. The usual management consists of heparin, aspirin, β-blockers, angiotensin-converting enzyme inhibitors, and statins. Clinical trials show that β-blocker therapy reduces infarct size and the frequency of recurrent myocardial ischemia and improves short- and long-term survival.

Evidence of successful fibrinolysis involves resolution of both chest pain and ST elevation. The rapidity with which these resolve is directly related to early patency of the affected artery. Reperfusion arrhythmias, typically manifested as a transient accelerated idioventricular arrhythmia, usually do not require additional antiarrhythmic therapy with lidocaine or amiodarone.

Immediate coronary angiography is not indicated unless recurrent ischemia, persistent ST elevation, or hemodynamic instability, including heart failure, occurs.
Bibliography

1. Kopecky SL. Effect of beta blockers, particularly carvedilol, on reducing the risk of events after acute myocardial infarction. Am J Cardiol. 2006;98:1115-9. Epub 2006 Aug 31. [PMID: 17027583]

Coronary artery **

A 32-year-old woman is brought to the hospital with chest pain after a party. She has had similar pain previously, primarily in the morning and rarely with exertion. The pain usually subsides spontaneously and occasionally is associated with diaphoresis but rarely with dyspnea. She almost lost consciousness at work during the most recent episode. The patient has occasionally inhaled cocaine. She is otherwise healthy and takes no medications. She has no family history of coronary artery disease.

On physical examination, blood pressure is 128/70 mm Hg and heart rate is 72/min. There is no jugular venous distention or carotid bruits. The lungs are clear, and cardiac examination shows a normal S1 and S2 and a faint mid-systolic click but no murmur. Electrocardiogram taken during the chest pain shows a 1-mV inferior ST elevation; a subsequent electrocardiogram taken after resolution of the pain is normal. Serum troponin concentration is elevated. Therapy with heparin, aspirin, metoprolol, and nitroglycerin is begun.

The next morning, coronary angiography shows a normal angiographic appearance of the arteries and normal left ventricular wall motion.

Which of the following is the most likely diagnosis?
A Coronary artery atherosclerosis
B Coronary artery dissection
C Coronary artery vasculitis
D Coronary artery vasospasm

Key Point
Coronary artery vasospasm is treated with nitrates in the short term and calcium channel blockers in the long term.

Answer and Critique (Correct Answer = D)

This patient has a presumptive diagnosis of myocardial infarction due to vasospasm of the coronary artery. Factors favoring this diagnosis are the normal angiographic appearance of the coronary arteries, use of cocaine, chest pain after a party (implying use of cocaine), and the episodic ST elevation with spontaneous resolution in the absence of fibrinolysis.

Coronary artery atherosclerotic disease is not likely, based upon the normal coronary artery catheterization. In addition to coronary artery vasospasm, other causes of myocardial ischemia or infarction in the absence of atherosclerotic coronary artery disease include coronary artery dissection, vasculitis (scleroderma and other connective tissue diseases), thromboembolism in the settings of endocarditis or paradoxical embolism, valvular disease, and hypertrophic cardiomyopathy. Spontaneous coronary artery dissection has been reported in pregnant women with or without hypertension but coronary artery dissection is unlikely in a nonpregnant woman Vasculitis seems unlikely in the absence of any additional signs or symptoms to support a diagnosis of collagen vascular disease. Endocarditis is unlikely in the absence of fever and a heart murmur, and hypertrophic cardiomyopathy is unlikely in the absence of a murmur and the normal electrocardiogram (following resolution of the chest pain).

The best treatment for coronary artery vasospasm is nitrates in the short term and calcium channel blockers over the long term. Angiotensin-converting enzyme inhibitors reduce mortality in patients with ST elevation myocardial infarction and in patients with a left ventricular ejection fraction <40% following an acute myocardial infarction. This patient meets neither of these criteria and is unlikely to benefit from this therapy. This patient should be strongly urged not to use cocaine.
Bibliography

1. Mirza MA. Angina like pain and normal coronary arteries. Uncovering cardiac syndromes that mimic CAD. Postgrad Med. 2005;117:41-6, 54. [PMID: 15948368]

Shock

A 53-year-old man with long-standing ischemic cardiomyopathy is admitted to the intensive care unit with hypotension following a 24-hour episode of viral gastroenteritis. He is given intravenous fluids. The following day he develops chest pain, shortness of breath, and mental status changes.

On physical examination, temperature is 38.2 °C (100.8 °F), heart rate is 100/min, blood pressure is 75/45 mm Hg, respiration rate is 12/min, and he is mildly lethargic. Jugular venous pressure is difficult to assess. The lungs are clear. Cardiac examination reveals regular rhythm, a normal S1 and S2, and the presence of an S3. There is peripheral edema bilaterally to the thighs, and the extremities are cool. A pulmonary artery catheter is placed and provides the following data.

Laboratory Studies
Central venous pressure

12 mm Hg (normal, 0-5 mm Hg)
Pulmonary artery pressure

40/15 mm Hg (normal, 20-25/5-10 mm Hg)
Pulmonary capillary wedge pressure

18 mm Hg (normal, 6-12 mm Hg)
Cardiac output

3.5 L/min (normal, 4-8 L/min)

Which of the following is the most likely diagnosis?
A Cardiogenic shock
B Hypovolemic shock
C Septic shock
D Toxic shock

Key Point
The pulmonary capillary wedge pressure is elevated and the cardiac output is low in patients with primary cardiogenic shock.

Answer and Critique (Correct Answer = A)

This patient has cardiogenic shock, manifested by hypotension and evidence of hypoperfusion (decreased mental status, cool extremities). The pulmonary artery catheter data show volume overload—central venous and pulmonary capillary wedge pressures are elevated. The volume overload and low cardiac output are most consistent with cardiogenic shock.

Septic shock and toxic shock are types of distributive shock, result from a severe decrease in systemic vascular resistance, and are often associated with an increased cardiac output and low pulmonary capillary wedge pressure. Although the patient was febrile, the hemodynamic data do not support either septic shock or toxic shock. Hypovolemic shock is associated with reduced pulmonary capillary wedge pressure, cardiac output, central venous pressure, and pulmonary artery pressure. Even though the patient had a bout of viral gastroenteritis that could result in hypovolemia, the hemodynamic data are most compatible with cardiogenic shock.
Bibliography

1. Summerhill EM, Baram M. Principles of pulmonary artery catheterization in the critically ill. Lung. 2005;183:209-19. [PMID: 16078042]

Cardiac Arrest

An elderly man collapses in an airport. A physician who witnesses the collapse checks his pulse and respirations and finds neither.

Which of the following is the most important determinant for short-term survival in this patient?
A Time to cardiopulmonary resuscitation
B Time to defibrillation
C Time to intubation
D Time to transport to the hospital


Key Point
Time to defibrillation is the most important determinant of survival in cardiac arrest.

Answer and Critique (Correct Answer = B)

Because most adults who suffer cardiac arrest initially demonstrate ventricular arrhythmias, time to defibrillation is the most important determinant of survival. Defibrillation within the first 4 minutes of ventricular fibrillation results in high survival rates, and the availability of automated external defibrillators in many public settings such as airports has made early defibrillation possible. Each minute that defibrillation is delayed reduces the chance of eventual hospital discharge by 8% to 10%.

Bystander cardiopulmonary resuscitation has been shown to improve survival, but prompt defibrillation is more important. Time to transport to the hospital does not correlate with survival—it is restoration of normal blood flow that is critical. Intubation helps provide adequate oxygenation but also is not as important as restoration of a normal cardiac rhythm.
Bibliography

1. Ali B, Zafari AM. Narrative review: cardiopulmonary resuscitation and emergency cardiovascular care: review of the current guidelines. Ann Intern Med. 2007;147:171-9. [PMID: 17679705]

Multivessel Coronary Artery Disease

A 69-year-old man has been treated medically for chronic stable angina for 7 years. Over the past 6 months, he has been noticing some mild neck discomfort brought on by playing tennis. He has a 15-year history of type 2 diabetes mellitus. His medications are metoprolol, aspirin, atorvastatin, and insulin.

Results of the physical examination are unremarkable. An electrocardiogram shows a pattern of left ventricular hypertrophy. Cardiac catheterization is performed and shows 90% stenosis in the proximal left anterior descending coronary artery, 85% stenosis in the middle right coronary artery, and 70% stenosis in the proximal left circumflex coronary artery. The left ventricular ejection fraction at rest is 40%.

Which of the following treatments would offer this patient the greatest improvement in longevity?
A Begin clopidogrel
B Begin dipyridamole
C Coronary artery bypass graft surgery
D Implantable cardioverter-defibrillator

Key Points

* Coronary artery bypass grafting improves survival in patients with obstructive left main and/or three-vessel coronary artery disease and reduced ejection fraction.
* Coronary artery bypass grafting improves survival in comparison to percutaneous intervention in patients with diabetes mellitus and multivessel coronary artery disease.

Answer and Critique (Correct Answer = C)

This fit, elderly man with no contraindications to coronary revascularization has the clinical features (three-vessel coronary artery disease [CAD] and left ventricular dysfunction) that warrant an invasive treatment approach rather than simply adjusting his medications. Patients who have CAD with large zones of ischemia benefit the most from interventional approaches added to their existing medical treatment. Patients with obstructive left main CAD and/or three-vessel CAD with a reduced left ventricular ejection fraction (≤40%) or a moderate to large amount of myocardial ischemia have improved survival rates with coronary artery bypass grafting (CABG) in combination with medical therapy as compared with medical therapy alone. Patients with multivessel CAD and diabetes mellitus have better outcomes with CABG compared with percutaneous angioplasty. Thus, CABG is preferable to a percutaneous intervention in these patients.

The implantable cardioverter-defibrillator has emerged as an important prophylactic treatment option for reducing sudden cardiac death in selected patients with CAD. An ejection fraction ≤30% helps to identify patients likely to benefit from this procedure. In this patient, the ejection fraction was reduced but remained above 30%. In addition, in patients with an ejection fraction ≤30% who are being considered for an implantable cardioverter-defibrillator, CABG remains the primary treatment when multivessel CAD is present. Thus, placement of an implantable cardioverter-defibrillator is not the best choice for this patient.
Bibliography

1. Stone KE, Chiquette E, Chilton RJ. Diabetic endovascular disease: role of coronary artery revascularization. Am J Cardiol. 2007;99:105B-112B. [PMID: 17307063]

Acute viral pericarditis

A 26-year-old woman is evaluated for sharp left precordial chest pain preceded by 2 to 3 days of sore throat, diffuse myalgias, and malaise. The chest pain is nonradiating and is aggravated by deep breaths. She does not have cough, dyspnea, fever, dizziness, or palpitations. She has always been healthy and does not use illicit drugs. A member of her immediate family was recently diagnosed with infectious mononucleosis.

On physical examination, her temperature is 36.7 °C (98 °F), heart rate is 95/min, respiration rate is 24/min, and blood pressure is 110/60 mm Hg. No lymphadenopathy is present, and the jugular veins are not distended. Lungs are clear. Cardiac examination is notable for an intermittent systolic “squeaky” sound along the left sternal border.

An electrocardiogram shows diffuse 1 to 3 mm of ST elevation with an upwardly concave configuration. An echocardiogram shows no pericardial effusion.

Which of the following is the most appropriate initial treatment for this patient?
A Clopidogrel
B Heparin
C Indomethacin
D Prednisone


Key Point
The initial treatment for acute viral pericarditis is a high-dose nonsteroidal anti-inflammatory drug.

Answer and Critique (Correct Answer = C)

This patient's sharp, pleuritic chest pain preceded by 2 to 3 days of prodromal symptoms is characteristic of acute viral pericarditis. The pericardial friction rub is suggestive of acute pericarditis, and the presence of ST segments that are upwardly concave on electrocardiography further supports this diagnosis. The lack of a pericardial effusion on echocardiography does not exclude pericarditis, given that 40% of patients with pericarditis may not have this finding.

The recommended initial treatment for acute viral pericarditis is a high-dose nonsteroidal anti-inflammatory drug such as indomethacin or ibuprofen. Indomethacin is rapidly tapered after 5 to 7 days because of the potential for toxicity with long-term use. Aspirin may also be used, although the high doses required may cause gastrointestinal problems.

If severe chest pain remains after 2 to 3 days of nonsteroidal anti-inflammatory drug treatment in patients with acute pericarditis, a 7- to 10-day tapering course of corticosteroids should be considered. However, corticosteroids such as prednisone have associated toxicity and are not recommended as first-line agents in the treatment of uncomplicated acute pericarditis. Low-dose colchicine may be used as an alternative to corticosteroids.

An acute myocardial infarction should always be considered in the setting of chest pain with ST elevation on electrocardiography. However, this patient's young age, viral prodrome, quality of the pain, and friction rub point to a diagnosis of acute pericarditis, and anticoagulation in a patient with known acute pericarditis is contraindicated because of the potential for hemopericardium.

Clopidogrel has no benefit as an anti-inflammatory agent for the treatment of acute pericarditis and is not indicated.
Bibliography

1. Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med. 2004;351:2195-202. Erratum in: N Engl J Med. 2005;352:1163. [PMID: 15548780]

Arterial ischemia

A 72-year-old man is evaluated in the office for bilateral leg pain and cramping after walking briskly up an incline. The pain is in the distal thigh and calf and is worse on the right side. He has no pain when walking downhill. The patient has a 100-pack-year smoking history, type 2 diabetes mellitus, hypertension, and heart failure. His medications are captopril, furosemide, atenolol, atorvastatin, metformin, and aspirin.

On physical examination, the blood pressure is 146/68 mm Hg and heart rate 82/min and regular. The lungs are clear. Cardiac examination reveals an S4. There is a right femoral artery bruit with absent pulses and mild dependent rubor. Ankle-brachial index is 0.8.

Which of the following is the most likely cause of this patient's symptoms?
A Arterial ischemia
B Osteoarthritis
C Peripheral neuropathy
D Right popliteal venous thrombosis
E Spinal stenosis

Key Points

* Most patients with peripheral vascular disease have an ankle-brachial index (ABI) <0.9, and those with severe disease (rest ischemia) have an ABI <0.4.
* An ABI >1.3 indicates vascular calcification.

Answer and Critique (Correct Answer = A)

The patient's history of exercise-induced leg pain, its relief with rest or walking downhill, vascular bruit and absent pulses on physical examination, dependent rubor, and several major risk factors for atherosclerotic artery disease all point to arterial ischemia as the cause of his symptoms. Determination of the ankle-brachial index (ABI) is a common initial test in the evaluation for peripheral vascular disease. With a Doppler probe, the ABI is measured as the ratio of the highest right/left dorsalis pedis/posterior tibial artery systolic pressure divided by the highest right/left brachial artery systolic pressure. A normal ABI is 1.0 to 1.3. Most patients with peripheral vascular disease have an ABI <0.9, and those with severe disease (rest ischemia) have an ABI of <0.4. An ABI >1.3 suggests a calcified, noncompressible vessel, most commonly seen in patients with long-standing diabetes mellitus and hypertension.

Peripheral neuropathy would be unlikely to present as pain with exercise. Spinal stenosis commonly presents as pain with standing and after walking a variable distance, most prominently with spinal extension, and is usually relieved by flexing forward, sitting, or lying down. Like spinal stenosis, osteoarthritis may cause pain on walking but is usually independent of grade; neither condition can account for the patient's other findings including bruit, diminished pulses, dependent rubor, and abnormal ABI. Popliteal venous thrombosis may present with localized pain and erythema, but the pain would not be exertional and cannot account for bilateral pain or the physical examination findings.

Bibliography
1. Khan NA, Rahim SA, Anand SS, Simel DL, Panju A. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA. 2006;295:536-46

Idiopathic pulmonary fibrosis

A 70-year-old man is evaluated in the office for dyspnea on exertion. He reports feeling well until about 8 months ago, when he developed slowly progressive shortness of breath. He also developed an intermittent dry cough. He does not have chest pain, fever, or chills. He has no other medical problems, has never smoked cigarettes, and takes no medications other than an occasional aspirin. He is a retired professor and has never worked outside of academia. His hobbies include golf and fishing.

On physical examination, the patient is dyspneic at rest and has digital clubbing. Temperature is 37 °C (98.6 °F), blood pressure is 130/82 mm Hg, heart rate is 90/min, respiration rate is 16/min, and oxygen saturation is 88% with the patient breathing room air. Pulmonary auscultation reveals bilateral basilar end- inspiratory Velcro-like crackles. Cardiac examination is normal.

Routine serologic studies and urinalysis are normal. Chest radiograph shows diffuse, predominantly basilar bilateral infiltrates.

Which of the following is the most likely diagnosis?
A Asbestosis
B Chronic obstructive pulmonary disease
C Cryptogenic organizing pneumonia
D Idiopathic pulmonary fibrosis
E Sarcoidosis



Key Points

* Idiopathic pulmonary fibrosis is characterized by basilar-predominant infiltrates on chest radiography, restrictive lung physiology, and evidence of impaired gas exchange.
* Physical examination clues compatible with idiopathic pulmonary fibrosis include digital clubbing and bibasilar end-inspiratory crackles with a Velcro-like quality.

Answer and Critique (Correct Answer = D)


This patient most likely has idiopathic pulmonary fibrosis, which is a specific form of chronic fibrosing interstitial pneumonia of unknown cause limited to the lung. It is characterized by predominantly basilar infiltrates on chest radiograph, restrictive physiology, and evidence of impaired gas exchange. Most patients with this disorder are more than 50 years old and develop progressive dyspnea and nonproductive cough, with many patients reporting symptoms of more than 6 months' duration before medical evaluation. Fever is rare, and when present, suggests an alternative diagnosis. Weight loss, fatigue, and malaise may be present. More than 80% of patients have bibasilar end-inspiratory dry crackles that have a Velcro-like quality. Cardiac examination may be normal or, in the case of advanced disease, show evidence of cor pulmonale. Digital clubbing occurs in 25% to 50% of patients. The next diagnostic steps in this patient include chest CT to evaluate the type of infiltrate and complete pulmonary function testing to confirm the presence of restrictive pulmonary disease with evidence of impaired gas exchange. Lung biopsy is often needed to establish the diagnosis.

Asbestosis is the best characterized of the occupational lung diseases and may present similarly to pulmonary fibrosis. Although asbestosis typically involves the lung bases, it is unlikely in the absence of an exposure history. On high-resolution CT scan, more than 90% of patients with asbestosis show some pleural abnormality such as pleural plaques or thickening. Chronic obstructive pulmonary disease is unlikely in a nonsmoker and in the absence of other irritant exposures. Additionally, this patient's chest radiograph is not consistent with chronic obstructive pulmonary disease, which typically includes hyperinflation, flattened diaphragms, and increased anterior-posterior diameter. Cryptogenic organizing pneumonia is characterized by a preceding flu-like illness in 40% of patients, with most patients reporting fewer than 3 months of symptoms before medical evaluation. This disorder may be associated with collagen vascular diseases, neoplasms, and viral illnesses. Chest radiograph may show unilateral or bilateral consolidation, with nodules in 10% to 50% of patients. High-resolution CT scan shows patchy air space consolidation in the periphery of the lung and often in the lower lung zones. This disorder often presents like a community-acquired pneumonia and is not compatible with this patient's slowly progressive disease. Sarcoidosis typically presents with bilateral hilar lymphadenopathy with or without infiltrates and may include extrapulmonary manifestations such as liver involvement, uveitis, or arthritis. High-resolution CT scan may show nodules along bronchovascular bundles with bilateral hilar and mediastinal lymphadenopathy.
Bibliography

1. Martinez FJ, Safrin S, Weycker D, Starko KM, Bradford WZ, King TE Jr, Flaherty KR, Schwartz DA, Noble PW, Raghu G, Brown KK; IPF Study Group. The clinical course of patients with idiopathic pulmonary fibrosis. Ann Intern Med. 2005:21;142:963-7. Summary for patients in: Ann Intern Med. 2005;142:I23. [PMID: 15968010] [PubMed]

CREST syndrome

A 48-year-old man is evaluated in the office for progressive exertional dyspnea and a nonproductive cough. He is an ex-smoker (30-pack-years) and has gastroesophageal reflux disease, hypertension, and hypothyroidism. His medications are a proton pump inhibitor, an angiotensin-converting enzyme inhibitor, and thyroid hormone replacement.

On physical examination, blood pressure is 140/88 mm Hg, heart rate is 86/min, and respiration rate is 16/min. The skin on the hand is shown (Figure 27). He has localized areas of skin thickening on the arms and chest. Bibasilar mid- to late-inspiratory crackles are audible. There is no peripheral edema.

High-resolution CT scan of the chest shows reticular lines that are most prominent in the periphery of the lower lobes, accompanied by patchy, ground-glass opacities. Pulmonary function testing shows an FEV1 84% of predicted, an FVC 78% of predicted, and a DLCO 39% of predicted. Antinuclear antibody titer is 1:160.

Which of the following is the most likely diagnosis?
A Hypersensitivity pneumonitis
B Idiopathic pulmonary fibrosis
C Systemic sclerosis (scleroderma)
D Systemic lupus erythematosus


Key Points

* Lung disease is the most common cause of morbidity and mortality in patients with systemic sclerosis (scleroderma).
* In systemic sclerosis, both interstitial lung disease and pulmonary hypertension can develop (independently or together) and have an adverse effect on outcome.

Answer and Critique (Correct Answer = C)

In patients with systemic sclerosis (scleroderma), the lung is commonly involved, and lung disease is now the most common cause of scleroderma-related morbidity and mortality. Scleroderma is suggested by the typical skin findings. Pigment changes appear first, followed by skin thickening, digital pitting, and ulceration. Skin changes can extend proximally; patients with skin findings proximal to the elbows have diffuse scleroderma, as does this patient. In patients with scleroderma, both interstitial lung disease and pulmonary hypertension can develop (either independently or together) and have an adverse impact on outcome. Pulmonary disease can also be the initial clinical manifestation of scleroderma and is most commonly associated with diffuse scleroderma. Pulmonary hypertension is more commonly associated with limited scleroderma (CREST syndrome: calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia). A comprehensive history and physical examination are necessary to identify and confirm the underlying cause. In this patient, the presence of gastroesophageal reflux disease, sclerodactyly, proximal skin findings, late crackles on examination, abnormal high-resolution CT scan findings, a restrictive pulmonary physiologic defect, and the positive antinuclear antibody titer suggest the presence of scleroderma-related interstitial lung disease.

Idiopathic pulmonary fibrosis is an idiopathic interstitial pneumonia (i.e., it occurs in the absence of other explanations for the lung disease). The presence of features suggestive of scleroderma excludes this diagnosis. Various intrathoracic complications occur in patients with systemic lupus erythematosus; however, classic interstitial lung disease is uncommon. The clinical diagnosis of hypersensitivity pneumonitis requires a specific exposure that is temporally related to the development of the lung disease, and the high- resolution CT scan pattern is generally one of centrilobular nodules with areas of focal air-trapping. In addition, hypersensitivity pneumonitis cannot explain the patient's skin findings and gastroesophageal reflux disease.
Bibliography

1. Steen VD. The lung in systemic sclerosis. J Clin Rheumatol. 2005;11:40-6. [PMID: 16357695] [PubMed]