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3 Free Guides are available by providing a stamped, self-addressed envelope(please specify guides). Cardiovascular emergencies are life-threatening disorders that must be recognized immediately to avoid delay in treatment and to minimize morbidity and mortality. Cardiopulmonary arrest is a sudden and unexpected loss of perfusing pulsatile blood flow attributable to cessation of cardiac mechanical activity.
These diseases can be generally classified into 5 H's and 5 T's (Hypovolemia, Hypoxemia, Hydrogen ion (acidosis), Hypo- or Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, and Thrombosis–both pulmonary and cardiac). The incidence of out-of-hospital and in-hospital cardiac arrests assessed by emergency medical services (EMS) in the United States in 2013 was estimated to be 424,000 and 209,000, respectively. The American Heart Association and European Society of Cardiology have published revised resuscitation guidelines in 2010,7,13,14 which included some key changes from the 2005 guidelines. Deliver advanced cardiac life support, such as intubation, establishment of intravenous (IV) access, and transfer to a medical center or intensive care unit. More emphasis on the quality of CPR performed, including the rate and depth of compressions, allowing complete chest recoil, and minimizing interruptions in compressions. Highlighting the importance of professional healthcare rescue teams performing multiple tasks during CPR such as establishing an airway or delivering advanced cardiac life support drugs. If the patient is in VF or pulseless VT, shock the patient once using 200 J on biphasic (on equivalent monophasic, 360 J). If there is persistent or recurrent VT or VF despite several shocks and cycles of CPR, perform a secondary ABC survey with a focus on more advanced assessments and pharmacologic therapy. Resume immediate post-cardiac arrest care if there is a return of spontaneous circulation as above. Check for serious signs of low cardiac output due to bradycardia such as hypotension, altered mental status, or acute heart failure. Consider glucagon for beta-blocker toxicity, calcium infusion for calcium channel blocker toxicity. If no serious signs or symptoms are present, evaluate for a type II second-degree atrioventricular block or third-degree atrioventricular block.
A hypertensive emergency is an acute, severe elevation in blood pressure accompanied by end-organ compromise. End-organ compromise includes acute renal failure due to nephrosclerosis, ocular involvement with retinal exudates, hemorrhages, or papilledema, hypertensive encephalopathy, acute stroke or intracranial hemorrhage, acute myocardial infarction, aortic dissection, and eclampsia.
Hypertensive emergencies result from an exacerbation of previously uncomplicated hypertension or have a secondary cause, including renal, vascular, pregnancy-related, pharmacologic, endocrine, neurologic, and autoimmune etiologies (Box 1). The prevalence of hypertension rises substantially with increasing age in the United States and is greater among blacks than among whites in every age group. Based on the third National Health and Nutrition Examination Survey (NHANES III), the prevalence of hypertension in those older than 70 years was found to be approximately 55% to 60% of the U.S. A British study has revealed that less than 1% of patients with primary hypertension progress to hypertensive crisis.
This study also showed that despite increasingly widespread therapy, the number of patients presenting with hypertensive crises did not decline between 1970 and 1993.
Any syndrome that produces an acute rise in blood pressure may lead to a hypertensive crisis. No large randomized clinical trials have assessed therapy in hypertensive emergency; therapeutic intervention is largely a result of expert opinion. IV vasodilator therapy to achieve a decrease in mean arterial pressure (MAP) of 20% to 25% or a decrease in DBP to 100 to 110 mm Hg within the first 24 hours is recommended.
At our institution, we focus on reducing shear forces and combine a beta-blocker with sodium nitroprusside (SNP).
In addition to reducing MAP and DBP with medications as described above, early surgical intervention for type A dissection has been proven to reduce morbidity and mortality. IV bolus hydralazine therapy is used occasionally in some institutions and departments to treat hypertensive urgency or emergency. IV magnesium (frequently used as a tocolytic during preterm labor), hydralazine (a pregnancy category B drug that should be utilized cautiously as described above), and labetalol (category B) have value in the treatment of preeclampsia and prevention of eclampsia.19 Angiotensin-converting enzyme inhibitors (category D) are generally avoided during pregnancy because their use has been associated with an elevated risk of fetal congenital malformations. Antihypertensive therapy in the context of ischemic stroke can be controversial in cases when recombinant tissue plasminogen activator is not used.27 For such cases, antihypertensive medications are generally not used during the first 24 hours, as long as the SBP does not exceed 220 mm Hg, and the DBP does not exceed 120 mm Hg. Aortic dissection is a tear of the aortic intima that allows the shear forces of blood flow to dissect the intima from the media and, in some cases, penetrate the diseased media with resultant rupture and hemorrhage (Fig.
While some older classification systems of aortic dissection (such as Stanford and DeBakey) still exist and are used, they seem anachronistic in the current era of advanced imaging. Most patients present with acute chest pain that peaks in intensity at onset, and is often self-described as "tearing" or "ripping" in nature. Chest radiographs may reveal an abnormality in approximately 70% to 80% of patients, such as a widened mediastinum or loss of the demarcation of the aortic knob, pleural effusion, or pulmonary edema.33 Importantly, a normal chest radiograph does not rule out aortic dissection.
The sensitivity of computed tomography angiography (CTA) for detecting aortic dissection is approximately 83% to 100%, and its specificity ranges from 87% to 100%, depending on the study.35,36 In the current age of ECG-gated CTA, the sensitivity and specificity for detecting dissections approaches 100%, and thus it is the diagnostic imaging modality of choice. Surgical therapy is the best option for acute aortic dissection involving the ascending aorta. In the hypotensive patient, diagnoses of pericardial tamponade, aortic rupture, aortic insufficiency, myocardial infarction, or a combination of these should be suspected and tested for.
Cardiogenic pulmonary edema results from an absolute increase in left atrial pressure, with resultant increases in pulmonary capillary and venous pressures. Left ventricular systolic dysfunction, left ventricular diastolic dysfunction, and obstruction of the left atrial outflow tract are the primary causes of increased left atrial pressure.
Diastolic dysfunction results in impaired left ventricular filling and elevation in left ventricular end-diastolic pressure. Left atrial outflow obstruction is often a result of valvulopathy, such as mitral stenosis or mitral regurgitation, but also can be caused by tumors (atrial myxoma), dysfunctional prosthetic valves, thrombus, and cor triatriatum. Pulmonary edema is diagnosed by the presence of various signs and symptoms, including tachypnea, tachycardia, crackles (reflecting alveolar edema), hypoxia (secondary to alveolar edema), and the S3 or S4 heart sounds, individually or in combination.
Laboratory data associated with pulmonary edema include hypoxemia on arterial blood sampling and a chest radiograph showing bilateral perihilar edema and cephalization of pulmonary vascular marking. Mainstays of immediate therapy include improving oxygen delivery to end organs, decreasing myocardial oxygen consumption, increasing venous capacitance, decreasing preload and afterload (with careful attention to MAP), and avoiding hemodynamic compromise. Nitroglycerin acts immediately to decrease preload and afterload.46 It should be used for the management of patients with pulmonary edema who are not hypotensive.
SNP is an effective vasodilator that is often required for the treatment of the hypertensive patient with pulmonary edema.47 Due to the rapid and potent effects of SNP, its use requires continuous invasive monitoring of arterial blood pressure. IV diuretics are most helpful for the treatment of volume overload in chronic congestive heart failure.
IV morphine can be used in certain select patients to decrease their "air hunger," anxiety, and sympathetic tone, which can in turn help reduce their afterload.
Cardiovascular emergencies are common in the practice of medicine and quick action is necessary.
Cardiopulmonary arrest has several possible causes, all of which require prompt resuscitative efforts. Hypertensive emergency causes end-organ damage and warrants admission for intensive monitoring, including continuous arterial blood pressure measurement, and treatment.
Aortic dissection categorized as Stanford type A requires emergent surgery, whereas type B is generally managed medically unless end-organ damage can be demonstrated. Acute pulmonary edema should be treated by improving oxygen delivery to end organs, decreasing myocardial oxygen consumption, and safely decreasing preload and afterload. Go AS, Mozaffarian D, Roger VL, et al; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
Januzzi JL, Sabatine MS, Eagle KA, et al; for the International Registry of Aortic Dissection Investigators.
Use these free images for your websites, art projects, reports, and Powerpoint presentations! Peripheral arterial disease (PAD), cerebrovascular disease, and coronary artery disease (CAD) are the three major syndromes of atherothrombosis. The risk factors for PAD are similar to the risk factors for atherosclerosis elsewhere (Fig.
PAD is more frequent in older adults, with a 1.5- to twofold increase in risk for every 10-year increase in age. Although diabetics often have extensive involvement, diffuse and advanced PAD appear to be related to the duration of diabetes rather than glycemic control. Other important risk factors include dyslipidemia (elevations of total cholesterol, low-density lipoprotein [LDL], triglyceride [TG], and lipoprotein(a) levels are all independent risk factors for PAD) and hypertension. Most patients with PAD are asymptomatic or present with atypical symptoms beyond those of classic intermittent claudication (IC; Box 2). In addition to leg symptoms, symptomatic patients often report poor quality of life related to their limited mobility and subsequent decline in overall functional capacity. Those with classic IC typically describe pain, ache, tightening, cramping, or sense of fatigue in one or more of the lower extremity muscle groups. A more detailed coronary assessment may be performed in select patients for whom coronary ischemic symptoms would otherwise merit such an assessment if CLI were not present (such coronary assessments should generally not impede associated CLI care).
The shortcomings of the ABI test include the potential to miss mild proximal disease of the aorta and iliac arteries (also referred to as inflow disease) in those with well-developed collaterals and those with significant medial artery calcification. The goals of PAD management are limb salvage, symptom relief, improving functional status, and preventing cardiovascular events (acute myocardial infarction [MI], stroke, and vascular death).
Current data regarding the benefit of aggressive diabetes management in PAD patients and its effect on morbidity or mortality are limited. Lipid-lowering therapy reduces the risk of new or worsening symptoms of intermittent claudication. The hyperlipidemia associated with PAD frequently is that of the metabolic syndrome (elevated TG [triglyceride], low high-density lipoprotein [HDL], and normal or slightly elevated LDL levels). More recently, the Heart Protection Study (HPS) has published evidence that supports the routine use of statins in patients with PAD regardless of their cholesterol levels. In this study, simvastatin significantly reduced the cardiovascular ischemic event rate by 23%.
Niacin or fibrate compounds may be considered for patients with elevated TG and low HDL levels once the target LDL level is reached.
The target blood pressure in hypertensive PAD patients is similar to that for patients who have CAD. The Heart Outcomes Prevention Evaluation (HOPE) trial documented a 22% reduction in the composite end points of MI, stroke, or cardiovascular death in patients with vascular disease or diabetes mellitus randomized to receive the ACEI ramipril compared with placebo.
A more recent analysis of this trial has concluded that the benefits of ramipril extend to symptomatic and asymptomatic PAD patients (the number needed to treat to prevent one ischemic event during the study treatment period of 4.5 years was 18 and 17 for symptomatic and asymptomatic patients, respectively). Given the increased risk of renal artery stenosis in this population, renal function should be monitored closely when starting a PAD patient on an ACEI or ARB. The CAPRIE trial has compared clopidogrel (Plavix, 75 mg daily) with aspirin (325 mg daily) in a study of 19,185 patients with atherosclerotic vascular disease, more than 6,400 of whom were enrolled on the basis of symptomatic PAD (intermittent claudication with abnormal ABI or prior revascularization or amputation).
Exercise, pharmacotherapy, and invasive (surgical or percutaneous) procedures are strategies that relieve exertional leg symptoms, increase ambulatory distance, and improve quality of life. A structured exercise rehabilitation program is one of the most effective strategies to improve claudication symptoms. Cilostazol (Pletal), is a reversible phosphodiesterase inhibitor that inhibits platelet aggregation, thrombin formation, and vascular smooth muscle proliferation, promotes vasodilation, and increases HDL and lowers TG levels. Cilostazol is the only FDA-approved medication to demonstrate consistent benefits on objective measures of exercise capacity and subjective measures of daily functioning and quality of life.
A dose of 100 mg twice daily (taken on an empty stomach at least ½ hour before or 2 hours after breakfast and dinner) is recommended to ensure effectiveness.
Pentoxifylline is a methylxanthine derivative that decreases blood viscosity and has hemorheologic (improves erythrocyte and leukocyte deformability), anti-inflammatory, and antiproliferative effects.
At present, the absolute indications for lower extremity revascularization are acute limb ischemia, critical limb ischemia (usually manifested as rest pain, nonhealing lower extremity ulcers), and lifestyle, vocational, or economically limiting claudication. Box 6 lists the accepted indications for revascularization in patients presenting with intermittent claudication. Reprinted with permission from Katzen BT: Clinical diagnosis and prognosis of acute limb ischemia. Short stenotic (or occlusive) lesions can generally be successfully treated percutaneously, whereas long lesions usually require surgical treatment. Careful patient selection and excluding patients with high bleeding risk are necessary to minimize hemorrhagic complications. Operative complications include myocardial infarction and stroke, wound or graft infection, peripheral embolization, and sexual dysfunction secondary to autonomic nervous system injury.
PAD is a prevalent systemic atherosclerotic disease with associated high cardiovascular morbidity and mortality. PAD is a common but underrecognized cause of morbidity particularly in older adults, those with diabetes, and smokers. The risk factors for PAD are similar to the risk factors of atherosclerosis elsewhere; risk factor modification is key to successful management and achieving favorable outcomes. Although intermittent claudication is the classic symptom of PAD, the vast majority of those affected are asymptomatic and diagnosed by an abnormal ABI value. Treatment of leg symptoms includes enrollment in a supervised walking program, use of cilostazol and, for select patients, percutaneous or surgical revascularization.
The PARTNERS program: A national survey of peripheral arterial disease detection, awareness, and treatment. The epidemiology of peripheral arterial disease: Importance of identifying the population at risk.
Atherosclerotic risk factors are less intensively treated in patients with peripheral arterial disease than in patients with coronary artery disease. The role of tobacco cessation, antiplatelet and lipid-lowering therapies in the treatment of peripheral arterial disease. Arteriosclerosis obliterans and associated risk factors in insulin-dependent and non–insulin-dependent diabetes.
Leg symptoms commonly reported by men and women with lower extremity peripheral arterial disease: Associated clinical characteristics and functional impairment. Risk factors and cardiovascular diseases associated with asymptomatic peripheral arterial occlusive disease.
Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Treatment of intermittent claudication with physical training, smoking cessation, pentoxifylline, or nafronyl: A meta-analysis. Treating tobacco use and dependence: An evidence-based clinical practice guideline for tobacco cessation.
Effect of simvastatin on ischemic signs and symptoms in the Scandinavian simvastatin survival study (4S).
Cholesterol reduction with atorvastatin improves walking distance in patients with peripheral arterial disease. The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Intensive blood pressure control reduces the risk of cardiovascular events in patients with peripheral arterial disease and type 2 diabetes. Beta-adrenergic blocker therapy does not worsen intermittent claudication in subjects with peripheral arterial disease. Effect of beta blockers on incidence of new coronary events in older persons with prior myocardial infarction and symptomatic peripheral arterial disease. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. Exercise rehabilitation for the patient with intermittent claudication: A highly effective yet underutilized treatment.
Effect of cilostazol, a phosphodiesterase III inhibitor, on experimental thrombosis in the porcine carotid artery.
Potentiation of anti-platelet aggregating activity of cilostazol with vascular endothelial cells. A dose-dependent increase in mortality with vesnarinone among patients with severe heart failure. A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia.
Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity.
A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. Thrombolysis in the management of lower limb peripheral arterial occlusion—a consensus document. Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions.
What is erectile dysfunction (ED)?Erectile dysfunction (ED) occurs when a man has repeated problems achieving or sustaining an erection.
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Recognition of seborrheic dermatitis is important for the primary care physician, because it may be associated with systemic disease, such as Parkinson's disease and human immunodeficiency virus (HIV) infection. Differential diagnosis includes psoriasis, atopic dermatitis, allergic or irritant contact dermatitis, and dermatophyte (tinea) infections.
Treatment includes medicated shampoos containing zinc pyrithione, selenium sulfide, salicylic acid, coal tar, or ketoconazole in combination with topical corticosteroids. Differential diagnosis includes verruca vulgaris (warts), epidermal nevus, melanocytic nevi, and melanoma. Differential diagnosis includes erythema multiforme, systemic lupus erythematosus (SLE), bullous pemphigoid, mastocytosis. Treatment includes elimination of known causes, antihistamines (H1 and H2 blockers), oral corticosteroids for acute flares, and, in refractory cases, immunosuppresants such as sulfasalazine and cyclosporine. Differential diagnosis includes urticaria, bullous arthropod reaction, drug eruption, and bullous pemphigoid. Differential diagnosis includes tinea versicolor, pityriasis alba, postinflammatory hypopigmentation, and hypopigmented mycosis fungoides.
Treatment includes broad-spectrum sunscreens, potent topical corticosteroids, topical calcineurin inhibitors (tacrolimus or pimecrolimus), narrow band ultraviolet (UV) B phototherapy, psoralen with UVA (PUVA) therapy, or total depigmentation for extensive disease. The most common cause of erythema nodosum in the pediatric population is streptococcal pharyngitis. Treatment includes identifying and eliminating known causes, bed rest and elevation of the extremities, aspirin or nonsteroidal anti-inflammatory medications (NSAIDs), colchicine, and supersaturated potassium iodide.
Pemphigus vulgaris can develop at any age, but it most commonly occurs in the fourth to sixth decades of life, usually in people of Mediterranean or Jewish ancestry.2 Morbidity and mortality are significant, even with treatment. Differential diagnosis includes bullous pemphigoid, Stevens-Johnson syndrome, and epidermolysis bullosa acquisita. Treatment includes good wound care for affected skin, systemic corticosteroids, various steroid-sparing immunosuppressants, rituximab, intravenous immunoglobulin (IVIg), and plasmapheresis.
Bullous pemphigoid occurs most commonly in the elderly, with an onset between 65 and 75 years of age. Differential diagnosis includes bullous SLE, epidermolysis bullosa acquisita, cicatricial pemphigoid, and dermatitis herpetiformis.
Treatment includes topical and systemic corticosteroids, steroid-sparing immunosuppressants, and tetracycline in combination with niacinamide.
Treatment includes topical and systemic corticosteroids, steroid-sparing immunosuppressants, colchicine, and plasmapheresis.
Differential diagnosis includes pilar or epidermal inclusion cyst, adnexal tumor, neurofibroma, and lipoma. Differential diagnosis includes allergic or irritant contact dermatitis (especially if bilateral), psoriasis, and dermatophyte (tinea) infection. Acanthosis nigricans can develop following the use of some medications, such as systemic corticosteroids, nicotinic acid, diethylstilbestrol, and isoniazid (INH).
Differential diagnosis includes confluent and reticulated papillomatosis of Gougerot and Carteaud and Dowling-Degos disease. Treatment for type I acanthosis nigricans includes identifying and removing the malignant tumor. Sweet's syndrome can occur with inflammatory bowel disease, bowel bypass syndrome, and pregnancy. Differential diagnosis includes erythema multiforme, deep fungal infection, pyoderma gangrenosum, and cutaneous metastases. Differential diagnosis includes pemphigus vulgaris, bullous pemphigoid, and erythema multiforme. Treatment includes treatment of the underlying malignancy, systemic corticosteroids, steroid-sparing immunosuppressants, rituximab, and plasmapheresis. Erythema gyratum repens is a rare but very distinctive skin disease characterized by reddened concentric bands in a whorled or woodgrain pattern.
Carney complex encompasses LAMB syndrome (lentigines, atrial myxoma, mucocutaneous myxomas, and blue nevi) and NAME syndrome (nevi, atrial myxoma, myxoid neurofibromas, and ephelides), entities known to pediatricians, cardiologists, and dermatologists. Differential diagnosis includes cutis laxa, Ehlers-Danlos syndrome, and perforating calcific elastosis. Ehlers-Danlos syndrome is a heterogeneous group of connective tissue disorders characterized by joint hyperextensibility, hypermobility, skin and vessel fragility, and fish-mouth scars.


Eleven types of Ehlers-Danlos syndrome have been identified with varying associated features, including mitral valve prolapse, blue sclerae, vascular aneurysm, aortic dissection, hernias, angina, gastrointestinal bleeding (perforation), and peripheral vascular disease. Sarcoidosis is a multisystem, granulomatous disease of the lungs, bones, central nervous system, lymph nodes, eyes, and skin.
Differential diagnosis includes rosacea, trichoepitheliomas, granulomatous syphilis, and granuloma annulare. Treatment includes TNF-α inhibitors, metrotrexate, NSAIDs, and steroid-sparing immunosuppressants. Lupus erythematosus is an autoimmune photosensitive dermatosis that can be localized or systemic, often with significant overlap. The cutaneous manifestations of SLE include malar erythema, photosensitivity, oral ulcers, discoid plaques, bullae, purpura, calcinosis cutis, and alopecia.
Differential diagnosis includes diabetic sclerodema, scleromyxedema, and chronic graft-versus-host disease. Treatment includes vasodilating drugs, phototherapy (UVA1) for limited disease, methotrexate, and cyclophosphamide. Reactive arthritis (Reiter's syndrome with conjunctivitis, urethritis, and diarrhea) (Fig.
Differential diagnosis includes psoriasis, juvenile plantar dermatoses, rheumatoid arthritis, ankylosing spondylitis, and gout. Treatment includes topical corticosteroids, cyclosporine, or acitretin for refractory disease. Erythema chronicum migrans, the hallmark of Lyme disease, reflecting early infection with the tick-borne spirochete Borrelia burgdorferi, develops as a red macule or papule at the site of the tick bite and gradually enlarges to an annular, reddened plaque (Fig.
Differential diagnosis includes cellulitis, spider bite, erythema multiforme, and erythema annulare centrifugum.
Diagnostic criteria include the aforementioned changes plus elevated creatine kinase or aldolase level, positive Jo-1 antibody, and electromyographic changes. Treatment includes systemic corticosteroids, methotrexate and other steroid-sparing immunosuppressants, and TNF-α inhibitors.
Differential diagnosis includes linear IgA dermatosis, bullous pemphigoid, scabies, contact dermatitis, and bullous lupus erythematosus. Acrodermatitis enteropathica is an inherited or acquired condition characterized by pustules, bullae, scaling in an acral and periorificial distribution, and concomitant zinc deficiency. Differential diagnosis includes other nutritional deficiencies, such as niacin or biotin deficiency, and necrolytic migratory erythema. Necrolytic migratory erythema (glucagonoma syndrome) is a rare disease characterized by erythematous, scaly plaques on acral, intertriginous, and periorificial areas, in association with an islet cell tumor of the pancreas. Necrolytic acral erythema, characterized by pruritic keratotic plaques on the upper and lower extremities, is a distinctive finding in hepatitis C infection and can resemble a deficiency dermatosis. Gardner's syndrome is an autosomal dominant cancer syndrome characterized by colonic polyposis, osteomas (maxilla, mandible, skull), scoliosis, epidermoid cysts, and soft-tissue tumors (fibromas, desmoids, lipomas). Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) is an autosomal dominant disorder characterized by numerous telangiectases on the skin and oral mucosa (Fig. Treatment includes estrogen therapy or oral contraceptives in postpubertal women, laser cauterization, selective embolization, and supportive care. Muir-Torre syndrome is a disorder characterized by one or more sebaceous tumors (adenoma, epithelioma, carcinoma) and one or more internal neoplasms, usually colorectal or genitourinary, rarely lymphoma. Peutz-Jeghers syndrome is an autosomal dominant disease characterized by lentigines on the skin (periorbital region, dorsal surfaces of the fingers and toes) and mucosa (lips, buccal mucosa) and hamartomas of the stomach, small intestine, and colon.
Differential diagnosis includes LEOPARD syndrome, Carney complex, and Cronkhite-Canada syndrome. Treatment includes regular and routine endoscopy and symptomatic treatment for hypogeusia and diarrhea.
Pyoderma gangrenosum is a neutrophilic dermatosis characterized by painful ulcers with boggy, undermined edges and a border of gray or purple pigmentation (Fig. Differential diagnosis includes infection, vasculitis, spider bite, and factitious disorder. Treatment includes treatment of underlying disease if applicable, local wound care, systemic and intralesional corticosteroids, cyclosporine, and infliximab.
Nephrogenic systemic fibrosis, also known nephrogenic fibrosing dermopathy, is a recently described disorder that resembles scleroderma.
Treatment includes immunosuppressive agents, phototherapy, topical steroids, retinoids, and photopheresis, all with little benefit. Birt-Hogg-Dubé syndrome is a disorder characterized by multiple fibrofolliculomas and trichodiscomas (skin-colored dermal papules on the face and trunk).
Porphyrias are inherited or acquired disorders of heme biosynthesis and can be erythropoietic, hepatic, or mixed in nature, each associated with a specific enzyme defect in the heme pathway.
Precipitating factors include alcohol ingestion, estrogen administration, certain hepatotoxins (dinitrochlorobenzene, carbon tetrachloride), HIV infection, hemochromatosis, and hepatitis C infection.
Differential diagnosis includes bullous SLE, epidermolysis bullosa acquisita, pseudoporphyria, and variegate porphyria.
Pseudoporphyria mimics porphyria cutanea tarda without an enzyme defect; plasma and urinary porphyrins are normal.
By recognizing cutaneous manifestations of systemic diseases, the internist can often determine the appropriate diagnosis and therapy or the need for referral to a dermatologist. Joly P, Benichou J , Lok C, et al: Prediction of survival for patients with bullous pemphigoid.
Kury S, Dreno B , Bezieau S, et al: Identification of SLC39A4, a gene involved in acrodermatitis enteropathica. High WA, Ayers RA , Chandler J, et al: Gadolinium is detectable within the tissue of patients with nephrogenic systemic fibrosis. Patients may present with severe hypertension, chest pain, dysrhythmia, or cardiopulmonary arrest. It occurs as a result of a multitude of cardiovascular, metabolic, infectious, neurologic, inflammatory, and traumatic diseases. The endpoint of these disorders is commonly pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF), pulseless electrical activity, or asystole. Among EMS-treated out-of-hospital cardiac arrests, 23% had an initial rhythm of VF or VT or were shockable by an automated external defibrillator.
This change was made to emphasize the importance of rapid initiation of chest compressions because in the old guidelines, significant time is potentially wasted performing airway evaluation. If the cardiac arrest is witnessed or downtime is shorter than 4 minutes, one shock may be administered immediately if the patient is in VF or pulseless VT followed by five cycles of CPR.
Pharmacologic therapy should include epinephrine (1 mg IV push, repeated every 3-5 min) or vasopressin (a single dose of 40 U IV, one time only).
This includes optimization of oxygenation and ventilation with emphasis on avoiding hyperventilation, treating hypotension by starting vasopressor infusion or inserting intra-aortic balloon pump, assessing neurologic status and starting induced hypothermia if indicated and assessing need for coronary reperfusion if high suspicion for acute coronary syndrome. Hypertensive encephalopathy signals the presence of cerebral edema and loss of vascular integrity. In patients with chronic hypertension, the vascular bed auto-regulates at higher blood pressure ranges compared with those with newly diagnosed hypertension.
Decreasing the MAP and DBP further should be done more slowly, over a period of days, because of the risk of decreasing perfusion of end organs.16 Several drugs have proved beneficial in achieving this goal (Table 1). In cases of marked catecholamine level elevation, large doses of IV beta-blockers may be required to achieve blood pressure reduction. We recommend against this practice, and using extreme caution with its use given the unpredictable pharmacodynamics and unpredictable blood pressure-lowering effects of IV hydralazine. This is because maintenance of a moderately-high cerebral perfusion pressure theoretically could confer neurological benefits. These include aging, hypertension, Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, bicuspid aortic valve (associated with medial degeneration), coarctation, and Turner's syndrome. Uncommonly, patients present with congestive heart failure from accompanying acute aortic valve insufficiency, tamponade, or both. The electrocardiogram (ECG) may reveal left ventricular hypertrophy, ST depression, T wave inversion, or ST elevation when the coronary arteries are involved. Studies have shown that delaying surgical intervention, even to carry out left heart catheterization, aortography, or both, results in worse outcomes.38-40 Mortality increases by 1% per hour while waiting for surgery.
Left ventricular systolic dysfunction is the most common cause of cardiogenic pulmonary edema.41 This dysfunction can be the result of coronary artery disease, hypertension, valvular heart disease, cardiomyopathy, toxins, endocrinologic or metabolic causes, or infections.
It is imperative to distinguish between mitral regurgitation and mitral stenosis, given their very different treatments. Additionally, if hypertension is present, it may represent diastolic dysfunction, decreased left ventricular compliance, decreased cardiac output, and increased systemic vascular resistance. Sublingual administration allows rapid delivery, which is often required to decrease preload. Their vasodilative and diuretic properties also are useful in the management of pulmonary edema.
The 2010 American Heart Association guidelines have proposed changes that make chest compressions a priority before assessment of airway and breathing, in order to minimize time delays. A comparison of bilevel and continuous positive airway pressure noninvasive ventilation in acute cardiogenic pulmonary edema [published online ahead of print August 6, 2013]. Efficacy of out of hospital defibrillation by ambulance technicians using automated external defibrillators: the Heartstart Scotland Project.
Experience with the use of automated external defibrillators in out of hospital cardiac arrest.
Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial. Precountershock cardiopulmonary resuscitation improves initial response to defibrillation from prolonged ventricular fibrillation: a randomized, controlled swine study. Hospital-wide first-responder automated external defibrillator programme: 1 year experience.
Bystander CPR, ventricular fibrillation, and survival in witnessed, unmonitored out-of-hospital cardiac arrest.
Impact of community-wide deployment of biphasic waveform automated external defibrillators on out-of-hospital cardiac arrest in Taipei. 2005 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Prevalence, treatment, and control of hypertension among African Americans and Caucasians at primary care sites for medically under-served patients.
Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000.
The failure of malignant hypertension to decline: a survey of 24 years' experience in a multiracial population in England. Results of long-term medical treatment of patients with arterial hypertension complicated by aortic dissection. Hypertensive and acute aortic syndromes [published online ahead of print September 20, 2013].
Diagnostic imaging in the evaluation of suspected aortic dissection: old standards and new directions. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. Characterizing the young patient with aortic dissection: results from the International Registry of Aortic Dissection (IRAD). Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Impact of organ malperfusion on mortality and morbidity in acute type A aortic dissections. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema—a systematic review and meta-analysis. Whereas luminal stenosis (or occlusion) and end-organ ischemia are late manifestations of this progressive process, the diagnosis of PAD is largely viewed as a measure of the individual's global systemic atherosclerotic burden.
As the population ages, the prevalence could reach 9.6 to 16 million in those age 65 and older and 19 million overall by 2050 (Box 1 and Fig. Smokers have at least double the risks of mortality, disease progression, and limb amputation rates compared with nonsmokers. Atherosclerotic lesions are plaques composed of a central lipid core, connective tissue, inflammatory cells, and smooth muscle cells, all covered by a fibrous cap.
A baseline electrocardiogram (ECG) should be obtained at the time of diagnosis and, for select patients, cardiac stress testing may be indicated. The ABI is the ratio of systolic blood pressure measured at the ankle by a Doppler ultrasound device to the higher systolic blood pressure at the brachial arteries (Fig. Thus, an exercise ABI should be determined when the resting ABI value is normal if the pretest probability of PAD is high. All PAD patients require intensive cardiovascular risk reduction and should be referred to a supervised exercise program. Smoking cessation leads to improvement in leg symptoms, lowers the amputation risk, improves long-term patency after revascularization, and reduces the cardiovascular event rate.27,28 Nicotine is one of the most potent addictive substances known to humans (comparable with heroin). The evidence supporting statin use in PAD patients dates back to the Scandinavian Simvastatin Survival Study (4S), which documented a 38% reduction in new or worsening claudication in the simvastatin group. Several reports have indicated that statins also improve pain-free walking distance and ambulatory activity in claudicants through a mechanism independent of their cholesterol-lowering properties. Thiazide diuretics, beta blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and calcium channel blockers are all effective. In addition to reducing the risk of fatal and nonfatal ischemic events, an ACEI may also increase peripheral perfusion and lead to improvement in walking distance. Revascularization procedures may also be required to prevent tissue loss, facilitate wound healing, and preserve the limb.
Maintenance of such a program should be considered indefinitely or the benefit may eventually be lost.
In randomized placebo-controlled trials, cilostazol has been found to be superior to placebo and pentoxifylline (Trental), which is also an FDA-approved medication for relieving claudication and improving pain-free and maximal treadmill walking distance, community-based ambulation, and quality of life. Since its approval for intermittent claudication in 1984, two meta-analyses and two systematic reviews have concluded that its effect on improving walking capacity is small, if any. Box 7 shows factors that increase the risk of limb loss in patients with critical limb ischemia, and Table 4 lists the clinical categories of acute limb ischemia. Percutaneous angioplasty carries a lower risk compared with surgical revascularization and can be performed on an outpatient basis.
Thrombus resolution allows for better visualization of underlying atherosclerotic lesions and offers an opportunity for simultaneous treatment with percutaneous angioplasty. Symptomatic PAD often impairs a patient's quality of life and untreated disease can lead to limb loss.
Effects on the risk of peripheral vascular complications, myocardial infarction and mortality.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE).
Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. It is intended for general information purposes only and does not address individual circumstances. 1) is a common chronic, superficial inflammatory disease of the scalp, face (especially the eyebrows and nasolabial folds), ears, and central chest, affecting 2% to 5% of the population. Patients who have had a cerebrovascular accident (CVA) can develop seborrheic dermatitis on the scalp in a unilateral distribution, corresponding to the affected hemisphere. Alternatively, fluconazole 400 mg (one dose) may be effective in combination with a mild topical corticosteroid. 2), the most common benign cutaneous neoplasms, are warty, age-related hyperkeratotic papules and plaques that appear anywhere on the body, most commonly the trunk.
3), or hives, is most often caused by medication (commonly penicillin or other antibiotics, sulfa drugs, aspirin) or food (shellfish, nuts, chocolate), and less often by infection.
Wheals in a fixed location for more than 24 hours suggest the possibility of urticarial vasculitis and warrant a skin biopsy. 4), a cutaneous hypersensitivity reaction, is usually caused by infection (herpes simplex virus or Mycoplasma pneumoniae) and less commonly by drug sensitivity (sulfonamides, barbiturates, antibiotics).
5) is characterized by a focal or generalized distribution of depigmented macules and patches. 6), the most common type of panniculitis, is characterized by painful, erythematous nodules on the shins and occasionally elsewhere. Other infectious causes include tuberculosis, gastrointestinal (GI) infections with Yersinia, Salmonella, or Shigella, and systemic fungal infections.
7) is an uncommon chronic and debilitating blistering disease characterized by painful mucosal erosions and flaccid blisters that become erosive. 8) is the most common bullous disease and is characterized by large, tense subepidermal blisters, which are often pruritic.
Prognosis is influenced by age and general condition of the patient, not by extent of disease activity.3 Treatment of older patients in poor health requires caution. 9) is an uncommon bullous disease characterized by skin fragility, milia (small cysts), scarring alopecia, and nail dystrophy.
11) is an uncommon condition characterized by unilateral eczematous plaque of the nipple and areola. Extramammary Paget's disease affects older adults and is often associated with an underlying adnexal (apocrine) carcinoma or an underlying cancer of the genitourinary tract or distal gastrointestinal tract. Occasionally, acanthosis nigricans is a marker of an underlying adenocarcinoma, especially of the gastrointestinal tract (60% gastric).
Treatment for types II and III includes weight loss and treatment of the underlying endocrine disorder, if applicable.
13), or acute febrile neutrophilic dermatosis, has a strong association with acute myelocytic or myelomonocytic leukemia. Affected patients have papules on the eyelids and extremities that become purpuric and ecchymotic due to increased blood vessel fragility secondary to amyloid infiltration of the vessels. 15), characterized by intractable stomatitis and blisters on the trunk and extremities, has features of pemphigus and erythema multiforme. 16), an acronym for lentigines, electrocardiographic changes, ocular telorism, pulmonary stenosis, abnormal genitalia, retarded growth, and deafness. Recognition of these syndromes is critical because identification and removal of the associated atrial myxomas may be lifesaving.
17) is characterized by yellow papules over redundant skin folds on the neck, abdomen, and groin, giving the skin the appearance of plucked chicken skin.
Ehlers-Danlos syndrome is characterized by abnormalities in collagen biosynthesis, which can affect many organ systems. Genetic testing for specific mutations has demonstrated redundancy and has reduced Ehlers-Danlos syndrome from eleven to seven types. Asymmetric fusiform swelling of the distal interphalangeal joints (sausage digits), in association with oligoarthritis and tenosynovitis can be seen in up to 70% of PsA patients. 20) is characterized by annular pink to red plaques in a sun-exposed, shawl-like distribution on the chest, back, and arms. The localized form, known as morphea, begins as erythematous patches that evolve into dusky, hypopigmented, indurated plaques with violaceous borders, usually on the trunk. In adults, dermatomyositis has a strong association with neoplasm, usually an adenocarcinoma of the breast, gastrointestinal tract, or lung. 25) is a chronic, intensely pruritic blistering disease characterized by symmetric grouped vesicles, papules, and wheals on the elbows, knees, scalp, and buttocks.
When inherited, acrodermatitis enteropathica results from a mutation in SLC39A, which encodes an intestinal zinc transporter.8 In infants, deficiency can follow breast-feeding, when maternal breast milk contains low levels of zinc. 26) associated with circulating type II cryoglobulins, usually yields palpable purpura on the lower extremities. 27) is characterized by violaceous, flat, polygonal papules, often on the flexor aspects of the wrists, trunk, medial thighs, genitalia, and oral mucosa.
This syndrome results from an inactivating germline mutation of the DNA mismatch repair genes, most often MSH-2.
The polyps are usually benign with low malignant potential, but patients have a 10 to 18 times greater lifetime risk of cancer, especially GI malignancies. Nephrogenic systemic fibrosis occurs in patients who have end-stage renal disease and are on dialysis and occasionally in patients with acute renal failure or after kidney transplantation. Patients have a significantly increased risk of renal oncocytoma and chromophobe renal carcinoma. Porphyria cutanea tarda, the most common porphyria, is a hepatic porphyria with acquired and sporadic forms (Fig. Manifestations of porphyria cutanea tarda include photosensitivity, skin fragility, bullae and erosions on sun-exposed skin (especially dorsal hands), and hypertrichosis.
Medications (NSAIDs [especially naproxen], furosemide, and tetracycline) are the most common cause of pseudoporphyria.
Box 1 outlines the most common cutaneous manifestations of diabetes, arranged by frequency of occurrence (most to least frequent). From acute febrile neutrophilic dermatosis to neutrophilic disease: Forty years of clinical research. In this chapter, we review the clinician's approach to these disorders and their treatments and provide links to other informative resources.


The value of early bystander cardiopulmonary resuscitation (CPR) and immediate defibrillation has been proven in many community-based studies. Airway evaluation and initiation of mouth-to-mouth breathing may be a complex, time-consuming process for the layperson, and may delay chest compressions. Establish IV access, identify rhythm, and administer drugs appropriate for rhythm and condition.
If left untreated, hypertensive encephalopathy may progress to seizure and coma.17,18 Aortic dissection is associated with severe elevations in systemic blood pressure and wall stress, requiring immediate lowering of the blood pressure and emergent surgery for type A dissection to reduce morbidity and mortality. Patients without chronic hypertension generally develop hypertensive crises at a lower blood pressure than those with chronic hypertension. Therefore, blood pressure should not be aggressively lowered in those with chronic hypertension, in whom a SBP of 130 mm Hg, for example, may cause end-organ hypoperfusion.
Laboratory evaluation should include measurement of the complete blood count with differential and smear evaluations, measurements of electrolyte, blood urea nitrogen, and creatinine levels, and electrocardiography, chest radiography, and urinalysis. An exception to this rule is the treatment of cocaine-induced hypertension, for which beta-blockers can induce unopposed alpha-mediated vasoconstriction, so direct-acting vasodilators and benzodiazepines are instead the mainstays of therapy. It can cause large, abrupt drops in blood pressure, which may lead to stroke and other end-organ damage. This approach more specifically identifies the major vessels and organs involved, allowing for superior anticipation of complications and improved decision-making.
Pregnancy poses a unique risk to women with any of these diseases because of increased blood volume, cardiac output, and shear forces on the aorta. The right coronary ostium is involved in 1% to 2% of aortic dissection cases, leading to an inferior myocardial infarction. Surgical repair in patients with type B dissection is generally reserved for those with end-organ compromise or those who do not respond to medical therapy. Pericardiocentesis should be avoided if tamponade is present, because immediate surgical intervention is the therapy of choice. We focus on cardiogenic pulmonary edema, which generally is more reversible than the noncardiogenic form. The presence of increased jugular venous pressure indicates increased right ventricular filling pressure secondary to right ventricular or left ventricular dysfunction. Two-dimensional transthoracic echocardiography is usually helpful in the acute setting to assess biventricular size and function, to identify valvular stenosis or regurgitation, and to determine the presence or absence of pericardial pathology. Administration of continuous positive airway pressure can increase gas exchange, and may perhaps decrease preload via increased intrathoracic pressure.43,44 In our experience, however, repeated attempts to improve oxygenation with noninvasive positive pressure ventilation often prove inadequate. IV administration of nitroglycerin also should be used in the nonhypotensive patient and, based on symptoms, titrated to a MAP of approximately 70 to 75 mm Hg. SNP should be used with caution in the setting of hepatic dysfunction, since the liver is responsible for transformation of the cyanide radical into thiocyanate.
Diuretics should be used with caution in the euvolemic patient to avoid compromising cardiac output and oxygen delivery. Thus, even the asymptomatic form of PAD is of great significance to both the patient and clinician.
1).1 Although PAD affects men and women equally, worse outcomes have been observed in diabetic women compared with diabetic men. The three risk factors most strongly associated with PAD are advanced age (older than 60 years), cigarette smoking, and diabetes mellitus (DM).
Plaques tend to localize at the bifurcations or proximal segments of large and medium-size arteries.
Recommended strategies for subjects presenting with critical limb ischemia are presented in Box 4. Recent data have not supported the routine use of dual antiplatelet therapy in this population. The limitations of exercise rehabilitation programs are cost, lack of availability, and insurance coverage. Most of these side effects, however, are short lived and rarely require discontinuation of the medication. Proposed predictors of favorable long-term outcomes include the locations of treated lesions (better results with iliac artery angioplasty compared with femoropopliteal or infrapopliteal arteries), quality of the underlying vessels (better with preserved inflow and distal runoff arteries), patient's comorbid conditions (worse in those who fail to abstain from tobacco, diabetics, or when the risk factors are poorly controlled), indication for the procedure (claudication better than acute or critical limb ischemia), and immediate postprocedure outcome (return of ABI to normal postintervention value).
Use of perioperative beta blockers is indicated because they significantly reduce the risk of cardiovascular complications (including MI and death). Despite the fact that PAD can be noninvasively and accurately diagnosed with the ABI, it often remains underdiagnosed and undertreated.
It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health. Clinically, the disease is characterized by thin erythematous plaques, often with a fine, greasy scale. Rarely, seborrheic keratoses indicate an underlying adenocarcinoma of the gastrointestinal tract if they appear suddenly in great numbers (sign of Leser-Trélat).
Chronic idiopathic urticaria for which no trigger can be identified often requires further testing such as serum radioallergosorbent testing (RAST) or skin prick-patch testing. Erythema nodosum occurs most commonly in young women, with a peak incidence between 20 and 40 years.1 In addition to the cutaneous findings, patients can have fever, malaise, arthralgias, or arthritis.
Less common causes include drug sensitivity (sulfonamides, salicylates, iodides, oral contraceptives or hormone replacement therapy), and a variety of systemic diseases, most often inflammatory bowel disease (Crohn's disease more than ulcerative colitis) and sarcoidosis. Skin disease typically follows trauma and occurs primarily on the hands, feet, elbows, and knees. Malignant acanthosis nigricans has a sudden onset and more extensive distribution, including the face, palms, and trunk.
Topical treatments including tretinoin, calcipotriol, urea, and salicylic acid may be helpful. Affected patients, usually middle-aged women, have painful erythematous to violaceous plaques on the face, extremities, and trunk. Direct immunofluorescence reveals deposition of IgG intercellularly and at the dermal-epidermal junction. Erythema gyratum repens has a strong association with lung cancer; the association with breast, cervical, and gastrointestinal cancers is less strong. Pseudoxanthoma elasticum represents a defect in elastic fibers, which become brittle and calcified. Patients with vascular (type IV) Ehlers-Danlos syndrome are prone to arterial rupture and have the highest mortality. Skin disease, affecting 25% to 35% of patients, includes red to purple indurated plaques of the nose (lupus pernio) (Fig.
Other presentations include symmetric polyarticular arthritis (15%), distal interphalangeal joint disease with nail damage (16%), arthritis mutilans with erosion of the phalanges (5%), and ankylosing spondylitis (5%).
19), usually localized to the head or neck, is characterized by atrophic, scarring plaques on sun-exposed areas.
The systemic or generalized forms are subdivided into CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias) and progressive systemic sclerosis. Implicated organisms include Campylobacter, Shigella, Salmonella, Ureaplasma, and Yersinia species. Affected patients can have fever, arthralgia, and myalgia, and, occasionally, Bell's palsy. Biopsy reveals a characteristic neutrophilic infiltrate, and direct immunofluorescence demonstrates deposition of IgA at the dermal-epidermal junction. Lichen planus also occurs with primary biliary cirrhosis and hepatitis B virus immunization. Recurrent epistaxis is the most common presenting manifestation of the syndrome, affecting approximately 85% to 90% of patients. The ulcers often follow trauma (pathergy) and begin as pustules or nodules that ulcerate and extend centrifugally.9 All body areas may be involved, but the legs are the most common site. Nephrogenic systemic fibrosis is characterized by thick, indurated plaques on the extremities and the trunk. The phrase "Look, listen and feel" has also been removed from the algorithm to prevent time delays.
Search for and treat identified reversible causes (5 H's and 5 T's), with focus on basic CPR and early defibrillation. Eclampsia, the second most common cause of maternal death, occurs from the second trimester to the peripartum period. Although the process is not completely understood, an initial rise in vascular resistance mediated by vasoconstrictors such as angiotensin II, acetylcholine, or norepinephrine is responsible for the acute increase in blood pressure. The most commonly used old classification system is the Stanford system; a dissection that involves the ascending aorta is classified as type A, and one that does not, only affecting the aorta distal to the left subclavian artery, is classified as type B (Fig. If hypotension persists, norepinephrine and phenylephrine are the vasopressors of choice because of their limited effects on increasing cardiac contractility. Finally, the presence of peripheral edema indicates a certain degree of chronicity to the patient's condition. The ECG may reflect ongoing ischemia, injury, tachycardia, and atrial or ventricular hypertrophy.
In such cases, restoration of oxygenation is best achieved via prompt endotracheal intubation and initiation of mechanical ventilation. Patients with renal dysfunction will tend to accumulate thiocyanate more rapidly than those with normal kidney function, since thiocyanate is excreted in the urine. For example, buttock, hip, and thigh claudication are seen with aortoiliac disease and calf claudication with femoral-popliteal disease. Paresthesia and paralysis imply irreversible ischemia, and muscle rigidity is a sign of a nonsalvageable limb.
Conventional contrast-mediated arteriography rarely is needed to establish the diagnosis of PAD; it is largely limited to patients being considered for revascularization procedures. Although primary stent placement in the iliac arteries appears to improve long-term patency rates, stent placement in the femoropopliteal area is reserved for special cases, such as suboptimal angioplasty result and flow-limiting dissection.
Generally, endarterectomy is feasible and offers an excellent success rate when used for proximal arterial segments (aorta, iliac, common femoral or profunda arteries) and bypass grafting is preferable for distal, long, or diffuse disease. With the availability of percutaneous and surgical techniques, the types of revascularization procedures should be individualized depending on the lesion characteristics, the risks for perioperative complications, and patients' preference.
Health care providers must make every effort to detect the disease at an early stage, assess associated risk factors, and provide proper long-term care.
Never ignore professional medical advice in seeking treatment because of something you have read on the BootsWebMD Site. Vitiligo commonly occurs in periorificial areas (mouth, orbits, vagina, anus) or at sites of trauma (hands, elbows, knees).
Biopsy reveals characteristic suprabasilar acantholysis and intraepidermal bullae formation. Immunofluorescence is similar to bullous pemphigoid, with IgG deposition at the dermal-epidermal junction. Skin biopsy reveals swollen, fragmented elastic fibers, and fundoscopic examination reveals angioid streaks in Bruch's membrane. 18), midfacial papules, annular plaques, and plaques or nodules on the trunk and extremities. Presence of anticentromere antibodies correlates with CREST syndrome; SCL-70 antibodies correlate with progressive systemic sclerosis. Affected patients, usually men, often have vesicles and crusted plaques on the penis (circinate balanitis) and erythematous pustules and papules on the palms and soles (keratoderma blennorrhagicum) that can mimic pustular psoriasis. Most patients have an asymptomatic gluten-sensitive enteropathy or, less commonly, thyroid disease.
Oral erosive lichen planus is the most common expression of lichen planus in hepatitis C patients. Telangiectases can involve the lungs, liver, brain, eyes, and gastrointestinal tract; hemorrhage can occur at any site. Fifty percent of patients have underlying rheumatoid arthritis or inflammatory bowel disease or, less often, a paraproteinemia, usually an IgA gammopathy. It is caused by a deficiency in uroporphyrinogen decarboxylase, leading to the accumulation of uroporphyrin in the urine and serum. Direct immunofluorescence reveals IgG and C3 at the dermal-epidermal junction and in vessel walls. It is characterized by the presence of seizures, coma, or both, in the setting of preeclampsia. This cascade exceeds the vasodilatory response of the endothelium, mediated primarily by nitric oxide. We then add SNP if needed because of its rapid onset and ease of titration, aiming for a MAP of 65 to 75 mm Hg. Endovascular stenting, a rapidly growing field, remains investigational in this acute setting and is sometimes used in very high-risk surgical patients with type B aortic dissections or aneurysms. In many cases, differentiating cardiogenic and noncardiogenic pulmonary edema can be challenging and requires the insertion of a pulmonary artery catheter to measure the pulmonary capillary wedge pressure. Finally, through its effects on coronary arteriolar resistance vessels, SNP can potentially cause coronary "steal," drawing blood flow away from ischemic myocardium.
Table 2 lists the recommended noninvasive vascular laboratory tests for lower extremity PAD by clinical presentation. While the topic was once taboo, awareness has skyrocketed with recent advances in treatment for ED. The disorder is often associated with autoimmune thyroid disease, insulin-dependent diabetes mellitus, pernicious anemia, or Addison's disease. Direct immunofluorescence reveals a chicken-wire pattern of deposition of immunoglobulin (Ig) G within the epidermis. Direct immunofluorescence reveals a linear deposition of IgG at the dermal-epidermal junction. Associated signs of pseudoxanthoma elasticum include hypertension, peripheral vascular and coronary artery disease, retinal and gastrointestinal hemorrhage, and stroke. More than 50% of patients have sacroiliitis, correlating with the presence of HLA-B27 antigen, but few patients have the classic triad of urethritis, conjunctivitis, and arthritis. Primary endemic areas in the United States are New England, the upper Midwest, and the Pacific Northwest.
Approximately 70% of patients have circulating IgA antibodies against the smooth muscle cell endomysium (antiendomysial antibodies), which are somewhat peculiar to dermatitis herpetiformis. Treatment includes topical and intralesional corticosteroids, topical immunomodulators, and phototherapy. Autopsies have demonstrated that disease is not limited to the skin; visceral organ and muscle fibrosis has been noted. Mechanical destruction of the endothelium by shear stress leads to further vasoconstriction, platelet aggregation, inflammation, and subsequent blood pressure elevation.
We generally co-administer nitroglycerin along with SNP to dilate conductance vessels and lessen this theoretical risk.
First, PAD is common (prevalence, 29%) in high-risk individuals (age older than 70 years without additional risk factors, or age 50 to 69 years with a history of cigarette smoking or diabetes) in the primary care setting.
These include rest pain, cold, or numbness of the feet, with or without tissue loss (nonhealing ulcers or gangrene). Erythema nodosum, an acute, painful panniculitis that usually affects the shins, is the most common nonspecific cutaneous manifestation of sarcoidosis. The rate at which this occurs determines the rate of increase in systemic vascular resistance as well as the acuity of a patient's presentation. Rest pain usually occurs at night (because of the horizontal position, which deprives the patient of the effect of gravity on blood flow through the tight lesions) and improves when the legs are in the dependent position. Third, patients who had both PAD and CAD were more likely to have been diagnosed than patients with PAD alone. Subsequently, superimposed edema of the affected leg(s) occasionally may be seen in those who tend to dangle their legs overnight. The mechanics of EDAn erection occurs when blood fills two chambers known as the corpora cavernosa. This causes the penis to expand and stiffen, much like a balloon as it is filled with water. Causes of ED: Chronic diseaseThe link between chronic disease and ED is most striking for diabetes (depicted here by a blood sugar test). Other conditions that may cause ED include hypertension, cardiovascular disease (atherosclerosis – narrowing of the arteries), Parkinson's disease and multiple sclerosis.
Causes of ED: LifestyleLifestyle choices that impair blood circulation can contribute to ED. Smoking, excessive drinking and recreational drug use may damage the blood vessels and reduce blood flow to the penis.
Smoking is a major contributor to atherosclerosis, making men particularly vulnerable to ED. Causes of ED: SurgerySurgery, including treatments for prostate or bladder cancer, can sometimes damage nerves and blood vessels near the penis. In some cases, the nerve damage is permanent, and the patient will require treatment to achieve an erection. Causes of ED: MedicationED may be a side effect of medication, including certain blood pressure drugs, antidepressants, tranquilisers and antihistamines. Men should talk to their doctor if they suspect a prescription or over-the-counter medication may be causing erectile problems. Causes of ED: PsychologicalED usually has something physical behind it, particularly in older men. Experts say stress, depression, poor self-esteem and performance anxiety can short-circuit the process that leads to an erection. These factors can also make the problem worse in men whose ED stems from something physical.
Diagnosing ED: Physical examinationTo diagnose ED, your doctor will ask you questions about your symptoms and medical history.
The doctor will conduct a complete physical examination to uncover signs such as poor circulation or nerve trouble. Your doctor will also look for abnormalities of the genital area that could cause problems with erections. Measuring testosterone levels can determine whether there is a hormonal imbalance, which is often linked to decreased desire. Blood cell counts, glucose and cholesterol levels, and kidney and liver function tests can reveal medical conditions that may account for ED.
A 2010 study suggests ED is a strong predictor of heart attack, stroke and death from cardiovascular disease. The researchers say all men diagnosed with ED should be checked for cardiovascular disease. This does not mean every man with ED will develop heart disease, or that every man with heart disease has ED, but patients should be aware of the link. Treating ED: Lifestyle changesMany men with ED are able to improve sexual function by making a few lifestyle changes. Giving up smoking, losing weight and exercising more often can help by improving blood flow. If you suspect a medication could be contributing to ED, talk to your doctor about adjusting your dosage or switching to another treatment. Treating ED: MedicationViagra (sildenafil), Cialis (tadalafil) and Levitra (vardenafil) are oral treatments for ED. They're generally taken up to an hour before sexual activity and should not be used more than once a day. It is given as an injection directly into the penis, as a pellet inserted into the urethra, or as a cream applied to the tip of the penis. Treating ED: Vacuum devices (pumps)Vacuum devices for ED, also called pumps, offer an alternative to medication. An elastic band worn around the base of the penis maintains the erection during intercourse. Treating ED: SurgeryIf ED is caused by a blockage in an artery leading to the penis, surgery can often restore blood flow.
Good candidates are typically younger men whose blockage stems from an injury to the groin or pelvis.
Treating ED: ImplantsIn men with persistent ED, a penile implant can restore sexual function. When an erection is desired, the man uses a pump to fill the cylinders with pressurised fluid. Another option is a malleable implant, which creates an erection with a surgically implanted rod.
Treating ED: PsychotherapyEven when ED has a known physical cause, psychotherapy can be beneficial. A therapist can teach the man and his partner techniques to reduce performance anxiety and improve intimacy. The UK regulator MHRA advises men to look for the Royal Pharmaceutical Society of Great Britain logo to show a website is linked to a registered pharmacy. Discussing ED with your partnerIt's natural to feel angry or embarrassed when dealing with ED, but don't forget that your partner is also affected. Talking openly about ED will help your partner understand the diagnosis and treatment options.



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Comments to «Ed cardiovascular disease statistics»

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