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David A. Bedell, MD

• Associate Professor of Family Medicine
• Roy J. and Lucille A. Carver College of Medicine
• University of Iowa
• Iowa City, Iowa

Optimal An estimated 60% of myocardial infarction deaths occur blood pressure is closer to 115/75 blood pressure youtube order zebeta cheap online, since in 40-70-year-olds within the first hour of symptom onset heart attack 3964 generic zebeta 5mg overnight delivery. It reduces the risk of myocardial infarction and stroke Normal Troponin T levels at 10-12 hours after symptom but increases risk of major bleeding blood pressure emergency level purchase genuine zebeta online. Prognostic tools are valuable when educating patients about possible outcomes arteria3d urban decay city pack cheap zebeta 10mg with mastercard, Cultural Considerations and when discussing and deciding upon treatment options arrhythmia game effective 5mg zebeta. Some clinical symptoms are more common in Achar S et al: Diagnosis of acute coronary syndrome blood pressure chart readings for ages order generic zebeta. A meta d01-ee21-442c-b84c-9535c326754b@sessionmgr4 analysis of randomized controlled trials. Mortality from coronary heart disease invasive intervention in acute coronary syndromes. Accessed Risk Assessment Tool for Estimating 10-year Risk of Developing August 3 2010. Paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, fatigue, and peripheral edema. These compensatory mecha Right ventricular failure: increased jugular venous pres nisms are rooted in the activation of the sodium-retaining sure, hepatomegaly, peripheral edema. In addition, 10% of the population may these neurohormones act both in an indirect and in a have isolated moderate to severe diastolic dysfunction, with directly toxic fashion to affect hemodynamic stressors and age greater than 65 years and female gender being consistent myocardial cell performance and phenotype. Causes of Cardiac Failure Based on this apparent bias, the possibility of biological changes associated with increasing age and female gender With the advent of improved hypertension treatment, earlier have been proposed as underlying reasons for the increased identification of valvular heart disease, and improved survival likelihood of diastolic heart failure in these populations. J Am Coll Cardiol 2003;41:217 Cardiomyopathies (dilated [idiopathic], hypertrophic, and restrictive) 223. Diabetes in the disease process can reduce morbidity and mortality and mellitus is one of the most significant factors for developing delay the onset of clinically evident disease (Table 20-2). Stage heart failure is increased compared with normoglycemic A includes those at risk but not manifesting structural heart women. Often-overlooked Stage C comprises the bulk of persons with heart failure who risk factors in the development of heart failure are smoking, have past or current symptoms and associated underlying physical inactivity or obesity, and lower socioeconomic sta structural heart disease. This is a sub ity health care, resulting in decreased adherence to treatment jective assessment that can change frequently, secondary to of modifiable risk factors such as hypertension, diabetes mel treatment response. A prompt diagnosis allows for early treatment Cardiology Foundation/; American Heart Association Task Force on Practice Guidelines. Developed in collaboration with with therapies proven to delay the progression of heart fail the International Society for Heart and Lung Transplantation. Symptoms and Signs is a clinical diagnosis for which no single examination or test the primary manifestations of symptomatic heart failure are can establish the presence or absence with 100% certainty. Acute increases in body weight are indicative is present in nearly all patients with heart failure and indi of fluid overload versus changes in body mass. Its absence makes heart disease of heart failure, blood pressure may be elevated or failure highly unlikely. The absence of dyspnea on exertion normotensive; and as the disease progresses, the blood pres essentially rules out the presence of heart failure due to left sure usually becomes low. A complete blood count is necessary to rule out anemia Nonspecific symptoms include chronic nonproductive cough, as a cause of high-output failure. Patients with right ventricular failure magnesium and calcium) analysis may reveal deficiencies, may present with right upper quadrant pain secondary to commonplace with treatment, which can make the patient hepatic congestion and peripheral edema. Hyponatremia is a poor prognostic No single clinical symptom has been shown to be both sign indicating significant activation of the renin-aldos sensitive and specific. Abnormalities on liver tests can has asymptomatic left ventricular dysfunction and the his indicate hepatic congestion. Thyroid function tests can tory alone is insufficient to make the diagnosis of heart failure. Fasting lipid profile, fasting However, a detailed history and review of symptoms remain glucose, and hemoglobin A level can reveal comorbid con 1c the best approach in identifying the cause of heart failure and ditions that may need to be better controlled. Physical Examination failure, thiamine testing is indicated to rule out deficiency the clinical examination can provide important information related to beriberi. Further testing to determine etiologic fac concerning the degree to which cardiac output is reduced tors of heart failure must be based on historical findings. The presence of size of the exacerbation and in turn increases and decreases an S3 has been found to be superior to S4 in identifying with each individual exacerbation. Left bundle branch block, left radiography for lowering the likelihood of heart failure. It provides important information concerning determine whether a structural abnormality is present. The finding of the various causes of heart failure, including ischemic heart left bundle branch block is an unfavorable prognostic indicator in disease, idiopathic cardiomyopathy, hypertensive heart dis patients with heart failure, among whom there is an increased 1 ease, and valvular heart disease. Echocardiography helps to year mortality rate from any cause, including sudden death. An increase in cardiac mass (left ven Ewald B et al: Meta-analysis of B type natriuretic peptide and N tricular hypertrophy) can be associated with hypertensive terminal pro B natriuretic peptide in the diagnosis of clinical cardiomyopathy versus cardiac remodeling, which is an adap heart failure and population screening for left ventricular dys function. Diastolic changes can be elucidated by Doppler Krishnaswamy P et al: Utility of B-natriuretic peptide levels in imaging. Left ventricular hypertrophy and a dilated left identifying patients with left ventricular systolic or diastolic atrium are clues to the possible presence of left ventricular dysfunction. Echocardiographic parameters useful in the pump function, and subsequent morbidity and mortality. Using clusters of clinical findings from the history, physi cal examination, and diagnostic tests is a better diagnostic Parameter Information Provided strategy than using isolated findings. The clinical examina Left ventricular function Normal value: 55%-60% tion enables the clinician to categorize patients as having low, (ejection fraction) Abnormal value: < 50% intermediate, and high pretest probabilities for the diagnosis Significant systolic dysfunction value: of heart failure. J Am Coll Source: Vitarelli A et al: the role of echocardiography in the Cardiol 2002;39:1151. The degree of left 30% of patients with dyspnea in the primary care setting, cli ventricular dysfunction, ventricular size, and shape add nicians need to consider differential diagnoses for dyspnea important prognostic information. If the body habitus of valvular heart disease, cardiac shunt, obstructive sleep apnea, the patient makes echocardiography impractical, radionu and severe obesity causing hypoventilation syndrome. Coronary with chronic systolic heart failure is the focus of the discus angiography should be strongly considered for patients with sion that follows. Wall motion abnormalities seen on echocardiography mended at earlier stages are applicable to and recommended or hibernating myocardium detected by dobutamine stress for later stages (see Table 20-2). Systolic Heart Failure and severity of wall motion abnormalities have been shown to correlate with the size of the myocardium at risk. Asymptomatic with cardiac structural abnormalities Myocar-dial Infarction Collaborative Group. Loop diuretics are the treatment of choice because they Accurate assessment of the cause and severity of heart fail increase sodium excretion 20%-25% and substantially ure, the incorporation of previous stage A and B treatment enhance free water clearance. Furosemide is most commonly recommendations, and correction of any cardiovascular, sys used, but patients may respond better to bumetanide or temic, and behavioral factors (Table 20-5) are important to torsemide because of superior, more predictable absorptions achieve control in patients with symptomatic heart failure. To minimize the risk of over Moderate dietary sodium restriction (3-4 g daily) with daily and underdiuresis, the diuretic response should guide the weight measurement further enhance volume control and dosage of loop diuretics (Table 20-7), with dose increases allow for lower and safer doses of diuretic therapies. Frequency of dosing is guided by training is beneficial and should be encouraged to prevent the time needed to maintain active diuresis and sustained physical deconditioning, which can contribute to exercise volume and weight control. As a lone treatment, however, they increase sodium excretion only 5%-10% and tend to decrease free water clearance overall. There is, however, some uncertainty Anemia regarding target doses achieved in clinical trials, and whether Uncontrolled diabetes mellitus these are more beneficial than lower doses. Developed in collaboration with the International Society for Heart and Lung Transplantation. Starting Because blockers may cause a 4 to 10-week increase in doses should be very low (see Table 20-7) but doubled at reg symptoms before improvement is noted, therapy should be ular intervals, every 2-3 weeks as tolerated, to achieve target initiated when patients have no or minimal evidence of fluid doses. Relative contraindications include bradycardia, heart rate, but low doses are beneficial and there appears to hypotension, hypoperfusion, severe peripheral vascular dis be a dose-dependent improvement. Race or gender differences in efficacy of outweighed by the beneficial effect of inhibiting sympathetic blocker therapy have not been noted. Current evidence suggests that these beneficial effects are not necessarily equivalent among D. Medications used in the treatment of symptomatic heart failure in patients with reduced left ventricular ejection fraction. Drug Therapy Initial Daily Dose Target or Maximum Daily Dose Loop Diuretics Bumetanide 1. If the additional treatment options include the aldosterone antag clinical situation does not allow for proper monitoring, the onists spironolactone and eplerenone (see Table 20-7). There risk of hyperkalemia may outweigh the benefit of aldos is no clear evidence to support the use of these therapies in terone antagonist therapy. Subsequent retrospective subgroup dropyridines (eg, nicardipine and nisoldipine) can worsen analysis of the trial discovered some survival improvement at symptoms of heart failure, especially in patients with moderate a serum digoxin concentration of 0. The newer long-acting dihydropyridine similar but nonsignificant survival trend was also noted in calcium channel blockers amlodipine and felodipine appear to women. Because survival is clearly worse when the serum be safe when used in the treatment of hypertension but do not digoxin concentration is greater than 1. Most antiarrhythmic drugs (except amio impaired renal function that adversely affects drug levels. Phosphodiesterase inhibitors (cilosta hydralazine and isosorbide dinitrate (H-I) is a reasonable zol, sildenafil, vardenafil, and tadalafil) can cause hypotension treatment in patients, particularly blacks, who have persist and are potentially hazardous in patients with heart failure. Despite this known risk the yearly therapy with biventricular pacing can improve quality of life, incidence of thromboembolic events in patients with stable functional class, exercise capacity, exercise distance, left ven heart failure is between 1% and 3%, even in those with lower tricular ejection fraction, and survival in these patients. A patients with a history of a thromboembolic event or those Bayesian meta-analysis. Other than for control of hypertension, cal analysis of randomized controlled trials. J Am Coll Cardiol cium channel blockers offer no morbidity or mortality benefit 2002;39:463. Diuretics are used to control symptoms of pulmonary therapy and dose-related outcomes in older adults with new congestion and peripheral edema, but care must be taken to heart failure in the community. Despite favorable trends in survival and advances in treat these patients can have rapid recurrence of symptoms, lead ment of heart failure and associated comorbidities, 50% of ing to frequent hospitalizations and a significant or perma patients die within 5 years of diagnosis. Control of fluid retention to improve symptoms is para Web Sites mount in this stage, and referral to a program with expertise in refractory heart failure or referral for cardiac transplanta American College of Cardiology clinical guidelines: tion should be considered. For example, Asian populations tend to have total lifestyle and pharmacologic therapy to lower serum choles cholesterol values 20%-30% lower than populations living terol. Evidence in support of using statin agents is particularly in Europe or the United States. It is important to recognize strong and has revolutionized the treatment of dyslipidemias. The efficacy of late with less likelihood of cardiovascular disease if they are primary prevention, (reducing the risk of disease occurrence below certain levels. They do not Ruptured or unstable plaques are responsible for clinical represent the opinions or official policy of the Department of the Air events such as myocardial infarction and stroke. Lipid lower Force, the Department of Defense, or the Uniformed Services ing, whether by diet or medication, can therefore be thought University. The first step begins after obtaining fasting should be considered before lipid lowering therapy is begun lipoprotein levels. The profile is categorized based on the or when the response to therapy is much less than predicted. They >240 High make no recommendation for or against screening in younger adults in the absence of known risk factors. Step 2 Identify the presence of coronary heart disease or equiva lents (coronary artery disease, peripheral arterial disease, Table 21-1. Obstructive liver disease Acute intermittent porphyria Step 4 Assess level of risk: use Framingham risk tables if 2+ risk Diabetes mellitus factors and no coronary heart disease (or equivalent) is Chronic renal insufficiency present. Chronic renal insufficiency Step 8 Identify the presence of the metabolic syndrome and treat. Step 7 reviews the options for drug therapy if required Step 4 uses the Framingham coronary risk calculator to (Table 21-4). Given 20%, moderate-risk, having greater than 2 risk factors, but a their proven efficacy, and enhanced patient compliance over 10-year risk of less than 10%, or low-risk, having 0-1 risk fac other classes of medications, statin agents are the drugs of first tors.

Nevertheless the rates vary greatly between and within countries and for some developing countries it doubles (Gilbert et al arteria alveolaris inferior cheap zebeta express. Other health consequences of pregnancy and childbirth are abdominal or perineal pain arteria jejunales proven 5 mg zebeta, infections arteria pulmonar zebeta 10mg, prolapse blood pressure viagra buy zebeta 2.5mg free shipping, fatigue hypertension treatment jnc 7 buy zebeta 2.5 mg otc, nausea arrhythmia lecture buy discount zebeta 10mg on-line, depression, and lactation complications (Goodburn et al. Plants serve as preventives, cures or relief for these symptoms in many developing countries where access to modern health care facilities is inadequate and birth commonly takes place at home. In these countries plants are also important in 3 family planning and have been shown to serve as fertility enhancers, abortifacient and contraceptives (Bourdy & Walter 1992, Jain et al. To find out the most common health issues and their cures in western medicine an interview was conducted with Annicka Stridh, who is employed as a midwife at the Swedish hospital Falu Lasarett. She stated that the most common health issue during puerperium was abdominal pain due to contraction of uterus. A literature search was done on plants and plant compounds used in traditional medicine to see if they may exhibit similar analgesic activity. Psychotria (Rubiaceae), a common genus in Southeast Asia, has attracted a considerable amount of pharmacological investigation. Both extracts and compounds found in Psychotria species showed analgesic activity (Elisabetsky et al. Plants in the family Solanaceae also proved to contain numerous species with analgesic effects, for example Mandragora officinarum and Solanum melongena (Vohora et al. One well known analgesic in clinical practice is morphine derived from opium poppy, Papaver somniferum, a species widely used in traditional medicine against pain and stomach problems. Secondary postpartum haemorrhage (haemorrhage after the first 24 h postpartum) is mainly caused by retained portions of placenta and infections (Drife 1997, Pelage et al. The pharmaceutical Syntocinon is given on a routine basis to women in Sweden before delivery. It contains a synthetic version of the naturally-occurring hormone oxytocin, released by the pituitary gland. Oxytocin causes the muscle of the uterus to contract and by that help start or continue labour and to control bleeding after delivery (A. A number of articles have been published on plants and plant extracts possessing an oxytocin-like effect. Extracts form Melastoma candidum tested on guinea pigs also gave an increased contraction frequency of uterus (Chou & Liao 1982) the use of plants as contraceptives and abortifacient may be difficult to investigate as these preparations are sometimes outlawed or cultures taboos, and informants are commonly reluctant to relay their knowledge. Some examples on plants used in family planning are Mimosa pudica (Mimosaceae) and Mussaenda pubescens (Rubiaceae). The project included interviews and collection of botanical specimens in five rural villages in the Central and Northern Laos. In total fifteen informants from the ethnic groups Akha, Brou, Hmong and Lanten participated. Plant use in traditional steam saunas was also included as a postpartum health procedure for lowland Lao in urban areas. Furthermore essential oils from selected species (Adenosma bracteosum, Alpinia cf. The analyses were performed in Sweden and aimed to determine bioactive compounds in these species and indicate their potential effect in comparison to western medicine. Dialect divergences and minor variations in dress, traditions, handicraft and house arrangements mark the differences between these groups (Chazee 1999). They are further subdivided into clans and lineages, and marriages are arranged between members of different clans, or subclans. The oldest male has virtually unlimited authority over its members and he is responsible for settling disputes between family members and make the final decisions (Symonds 2004). Hmong belong to the Miao-Yao language group of the Sino-Tibetan family (Ovensen 2004). The exact origin of Hmong, or Miao/Yao speaking people, is unclear but they lived in the highlands of south-western China for centuries. The Chinese government attempts to subjugate and settle the Hmong led to periods of protracted conflicts, and in the nineteenth century many Hmong migrated to Laos, into Burma (Myanmar) and Vietnam, and eventually also to Thailand (Anderson 1993, Tapp et al. In their new homelands Hmong descendants, like their ancestors 5 settled in high altitudes and continued the practice of swidden agriculture and opium (Papaver somniferum) cultivation. In 1975 when United States withdrew and further Lao came under communist regime thousands of Hmong (soldiers with their families) fled to Thailand fearing for their lives. Many of these Hmong were placed in refugee camps, and some were later resettled in Australia, Canada, France, French Guyana and the United States (Tapp 1986, 1988, Anderson 1993, Reineke 2001). The Hmong are still today struggling for their rights in Laos and challenged not only by resettlements and opium eradication but also by poor access to education, unemployment, and lack of land for cultivation. Village structure Hmong villages can vary greatly in size, partly depending on land available for cultivation. There is no fence around the village and it does not have gates like Akha villages. The construction and the location of the house is important and often village-wide social event. Both the location of the village and houses within it are chosen with great care, as it is important that the site is acceptable to the ancestors. The doors are never opposite to each other, and a spirit altar is on the wall facing the front door (Khao Toh, personal communication). Gender and division of labour Gender roles are pronounced in the traditional Hmong family. Women are responsible for the domestic work including cleaning, feeding animals, cooking and childcare. Hunting animals is restricted to the men; women are only allowed to kill chickens. Both men and women work with slashing and burning the fields and harvesting of the rice (Moua 2003). This is consistent with the idea that men make up the structure of the society on which all else is built. Hmong women conform to this view and give less prestige to themselves than to men. They believe that men have better judgment than women and men are both more intelligent and more capable. The reason, men have the power to make houses are built directly on the ground and each has two doors, the entrance formal and final decisions in most door and the spirit door. Religious believes: the natural and supernatural world Hmong are animists and believe that the physical and spiritual worlds coexist. These are the spirits of the forests, fields, rivers, hills, valleys, trees, rocks and even wind currents. They offer protection from the wild spirits of the outside, but can also cause illness or even death if they are not cared for and treated with honour and respect (Symonds 2004). The Hmong believe that the body contains various souls, the number of souls can vary between different Hmong groups but the concept of souls and soul loss remains similar across groups. The first soul enters the body as soon as the bone structure starts to form and will always reside in the body, even after death it stays with the bones in the grave to guard them. The second soul is brought by the wind at the moment the child takes its first breath. At death this soul makes the journey back to the land of darkness to join the ancestors, and is fed and remembered by its descendants. It reincarnates or wanders between the land of darkness and light with the shifting stages between life and death in a never-ending cycle (Symonds 2004, Sperstad & Werner 2005). Illness, Spiritual Healers and Shamans In Hmong culture; society, religion and medicine are connected and cannot be separated easily into categories. Beliefs and practices about childbearing, birth and childcare are closely inter-convened in the cultural beliefs of the natural and supernatural world. In health care both worlds are important as illnesses are considered to be sent by the spirits, or a result of being out of balance. Both neglecting the good spirits of ancestors or of the household, as well as catching the attention of wild spirits can be reasons for illness. A person can also easily lose a soul if frightened by a loud noise, a fall, or an animal, which can lead to serious illness or death if it is not restored by a shaman (Symonds 2004). A Shaman is a man or a women that been chosen by the spirits, this often reveals in a long illness, which is cured only when the person consents to become a shaman. Usually a shaman is consulted when the illness is very serious and cannot be cured by the soul calling rituals made by the family or by the sole use of medicinal Fig. For example if a woman does not follow a special diet and obey the restrictions in behaviour during the postpartum month she may experience physical problems like headaches, joint/back pain, excessive haemorrhage or a prolapsed uterus (Kao Tho, personal communication, Symonds 2004). Due to the vulnerable state after childbirth as well as during pregnancy it is also important to avoid streams and other bodies of water because of the presence of malevolent spirits (Tsia hua moa, personal communication). Midwives Midwives are respected and known in the village for their knowledge about pregnancy and birth. They can deal with complications during birth like turning a breech baby to the right position and can recommend herbs for fertility and birth. A shaman might also assist if complications arise during birth, he will perform rituals seeking the answers for the complications in the spiritual world (Symonds 2004). Fertility Fertility is important both to Hmong women and men, as it provides the opportunity of rebirth. Many children are appreciated as the infant-mortality rate is high and children are a good help in the fields. She can then seek help from an herbalist that possesses knowledge about fertility-enhancing herbs. Nevertheless the first child is believed to seal the marital union and if the wife remains childless the husband may seek divorce (Symonds 2004). Another reason why contraception is avoided is that a woman who expresses her wish of not having more children might fear that the husband take a junior wife. It is believed (but not taken very seriously today) that a women must give birth to more children than did her own mother or mother-in-law if she is to fulfil her destiny (Symonds 2004). Sons are highly appreciated as they carry the clan name along, but a great value is also placed on having an equal number of sons and daughters because of the bride price a family receives in exchange for its daughters (Moua 2003). Childbirth Birth consists of two parts, the actual physiological event, and the soul calling ceremony on the third day after birth, when the baby is given a name and its last soul enters the body. A supply of chicken for the new mother has to be arranged, and herbs have to be picked to serve as pain relief and to make decoctions to wash the newborn. The delivery took place in a sitting position where the husband normally was supporting the woman from behind. She says that most births take place alone and point out the importance of privacy. All other blood from the delivery also has to be buried with care as the mother and child risk getting sick if the wild spirits finds it (Symonds 2004). During this time it is of highest importance that the mother and child are kept warm and a bed is made up next to the fire (Rice 2000, Symonds 2004). The mother should also shower in warm water and eat warm food and drinks up to 30 days after birth. In order to return her body to balance and regain strength and weight she eats a special postpartum diet, usually a combination of herbal teas, boiled chicken with herbs, rice and eggs (Potter & Whiren 1982, Lewis & Lewis 1984, Symonds 2004).

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Syndromes

• Tremor
• Underactive thyroid gland
• If you have bleeding problems or if you take blood thinning medicines such as warfarin, clopidigrel, or aspirin
• Upper GI series (barium swallow x-ray)
• Putting ice on the knee
• Help relieve some breathing problems
• Carbamazepine: 5 to 12 mcg/mL
• Injury to a blood vessel or nerve

References

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