By Marc S Sabatine
The Pocket drugs guide from Massachusetts normal health facility, Boston, offers key medical information for college students and citizens. It comprises parts of inner medication, cardiology, pulmonary, gastroenterology, nephrology, hematology-oncology, infectious ailments, endocrinology, and rheumatology.
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Additional info for Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine (Pocket Notebook Series)
ESRD • Congenital (ie, bicuspid AoV w/ premature calcification): cause in 50% of Pts Ͻ70 y • Rheumatic heart disease (AS usually accompanied by AI and MV disease) • AS mimickers: subvalvular (HCMP, subAo membrane), supravalvular Clinical manifestations (usually indicates AVA Ͻ1 cm2 or concomitant CAD) • Angina: c O2 demand (hypertrophy) ϩ T O2 supply (T cor perfusion pressure) Ϯ CAD • Syncope (exertional): peripheral vasodil. w/ fixed CO S T MAP S T cerebral perfusion • Heart failure: outflow obstruct ϩ diastolic dysfxn S pulm.
7:1; usually involves root/asc Ao or descending Ao (arch & thoracoabd rare) Risk factors: HTN; atherosclerosis; aortitis (Takayasu’s, GCA, spondyloarthritis, syphilis); congenital (bicuspid AoV,Turner’s); connective tissue diseases (Marfan, Ehlers-Danlos type IV); familial; chronic Ao dissection; trauma • AAA: 5% prev. in individuals Ͼ65 y; 5–10ϫ more common in ɉ than Ɋ; most infrarenal Risk factors ϭ risk factors for atherosclerosis: smoking, HTN, hyperlipidemia, age, FHx Pathophysiology (NEJM 2009;361:1114; Nat Med 2009;15:649) • LaPlace’s law: tension across a cylinder ∝ [(⌬P ϫ r) / (wall thickness)] • TAA: cystic medial necrosis (medial degeneration, mucoid infiltration, apoptosis) • AAA: atherosclerosis & inflammation S matrix degeneration S medial weakening • Inflammatory and infectious (“mycotic”) aneurysms rare Screening (JAMA 2009;302:2015) • TAA: no established population screening guidelines • AAA: ✓ for pulsatile abdominal mass in all Pts; U/S for all men Ͼ60 y w/ FHx of AAA and all men 65–75 y w/ prior tobacco use ( J Vasc Surg 2004;39:267; Annals 2005;142:203;) Diagnostic studies (Circ 2005;111:816) • Contrast CT: quick, noninvasive, good Se & Sp for all aortic aneurysms • CXR: often abnormal, but not definitive in TAA • Abdominal ultrasound: screening and surveillance test of choice for AAA • TTE/TEE: useful for root and rest of TAA • MRI: preferred for aortic root imaging for TAA, but also useful in AAA Treatment (Circ 2006;113;e463; 2008;177:1883; 2010;121:1544) • Risk factor modification: smoking cessation, LDL-C Ͻ70 mg/dL; ?
Split if severe outflow obstruction, ᮍ S4 (occ. 3 suggestive, as is septum Ͼ15 mm; other findings include dynamic outflow obstruction, SAM, MR • MRI: hypertrophy ϩ patchy delayed enhancement (useful for dx & prognosis) • Cardiac cath: subaortic pressure ∇; Brockenbrough sign ϭ T pulse pressure postextrasystolic beat (in contrast to AS, in which pulse pressure c postextrasystole) Treatment (NEJM 2004;350:1320) • Heart failure ᮎ inotropes/chronotropes: ␤-blockers, CCB (verapamil), disopyramide. Vasodilators only if systolic dysfxn.
Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine (Pocket Notebook Series) by Marc S Sabatine