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321. Stroke Anticoagulation and Prophylaxis (Overview)

) In patients with aortic atheromas identified on echocardiography, the ideal strategy for stroke prevention remains uncertain. Mixed outcomes have been reported for anticoagulation therapy; plaque stabilization with statins appears promising. Neither approach has been tested in randomized, controlled trials. [ ] Dissections of internal carotid and vertebral arteries The majority (85-95%) of ischemic symptoms after dissection of brain-supplying arteries are caused by emboli from the site of the dissection (...) anticoagulation to achieve a higher target INR (target INR, 2.5-3.5 or 3.0-4.0), switching from warfarin to therapeutic doses of unfractionated heparin or low-molecular weight heparin, or adding an antiplatelet agent to warfarin. [ ] Because the lupus anticoagulants may interfere with INR determination, monitoring these patients using the prothrombin-proconvertin time and the chromogenic factor-X assay would be preferable. However, these tests are expensive and are not widely available. Previous Next

2014 eMedicine.com

322. Cardiomyopathy, Dilated (Overview)

Comprehensive metabolic panel Thyroid function tests Cardiac biomarkers B-type natriuretic peptide assay Chest radiography Echocardiography Cardiac magnetic resonance imaging (MRI) Electrocardiography (ECG) In many cases of cardiomyopathy, endomyocardial biopsy is class II (uncertain efficacy and may be controversial) or class III (generally not indicated). Class II indications for endomyocardial biopsy include the following: Recent onset of rapidly deteriorating cardiac function Patients receiving (...) coxsackievirus B was isolated from the myocardium of a newborn baby with a fatal infection. Advances in genetic analysis, such as polymerase chain reaction testing, have aided in the discovery of several viruses that are believed to have roles in viral cardiomyopathies. Viral infections and viruses associated with myocardial disease may be caused by the following: Coxsackievirus (A and B) [ ] Influenza virus (A and B) Adenovirus Echovirus Rabies Hepatitis Yellow fever Lymphocytic choriomeningitis Epidemic

2014 eMedicine.com

323. Cardioembolic Stroke (Overview)

of cardioembolic stroke. The diagnosis is based on the triad of (1) identification of a potential cardiac source of embolism, (2) absence/exclusion of other potential sources of cerebral ischemia, and (3) consideration of clinical neurologic features, as described in Evaluation in Suspected Cardioembolic Stroke, above. Seizures and epilepsy should also be considered in the differential diagnosis. Previous Next: Recommended Tests Blood cultures If fever or leukocytosis is present, blood cultures for infective (...) of randomized controlled trials. Stroke . 2007 Feb. 38(2):423-30. . Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med . 2011 Sep 15. 365(11):981-92. . Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med . 2009 Sep 17. 361(12):1139-51. . Connolly SJ, Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S, et

2014 eMedicine.com

324. Hypertensive Heart Disease (Overview)

, and monitoring the adverse effects of therapy. The tests to be ordered depend on clinical judgment regarding the etiology of hypertension. Recommendations from the Seventh Report of the Joint National Committee (JNC7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure include carrying out the following baseline laboratory workup before initiating treatment for hypertension [ ] : Electrocardiogram Urinalysis Blood glucose and hematocrit levels Serum potassium, creatinine (...) (or the corresponding estimated glomerular filtration rate [GFR]), and calcium measurements Lipid profile after a 9- to 12-hour fast - Includes high density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides Optional tests - Include measurement of urinary albumin excretion or albumin/creatinine ratio Cardiovascular risk assessment New guidelines on the assessment of cardiovascular risk, released in late 2013 by the American Heart Association/American College of Cardiology

2014 eMedicine.com

325. Erectile Dysfunction (Overview)

is a thorough history that includes the following: Sexual history Medical history Psychosocial history A physical examination is necessary for every patient, emphasizing the genitourinary, vascular, and neurologic systems. A focused examination entails evaluation of the following: Blood pressure Peripheral pulses Sensation Status of the genitalia and prostate Size and texture of the testes Presence of the epididymis and vas deferens Abnormalities of the penis (eg, hypospadias, Peyronie plaques (...) ) There is a strong correlation between hypertension and ED. There is also a correlation between benign prostatic hyperplasia and ED, though the causality is unclear. See for more detail. Diagnosis Laboratory testing for ED depends on information gathered during the interview; it is necessary for most patients, although not for all. Such testing may include the following: Evaluation of hormonal status (testosterone, serum hormone–binding globulin, luteinizing hormone [LH], prolactin, thyroid-stimulating hormone

2014 eMedicine.com

326. Heart Failure (Treatment)

and angina have demonstrated symptomatic and survival improvement with coronary artery bypass grafting (CABG) in studies; however, the trials did not include individuals with heart failure or those with severely reduced ejection fractions. [ ] In patients with angina and ventricular dysfunction, evaluation with coronary angiography should not be delayed (see ). Noninvasive cardiac testing is not recommended in patients with significant ischemic chest pain, as revascularization is advised (...) in these patients independent of their degree of ischemia/viability. [ ] Although there are no reports of controlled trials evaluating heart failure without angina and their outcomes with coronary revascularization, surgical revascularization is recommended in those with significant left main stenosis and in those with extensive noninfarcted but hypoperfused and hypocontractile myocardium on noninvasive testing. [ ] In patients with heart failure and reduced left ventricular (LV) ejection fraction but without

2014 eMedicine.com

327. Diabetes Mellitus, Type 2 (Treatment)

or insulin secretagogues. [ ] These effects may induce or worsen heart failure in patients with left ventricular compromise and occasionally in patients with normal left ventricular function. TZDs have not been tested in patients with New York Heart Association class III or IV heart failure. Fluid retention from TZDs has been considered resistant to treatment with loop diuretics, because of upregulation of renal epithelial sodium channels. However, a randomized, double-blind, placebo-controlled

2014 eMedicine.com

328. Cardiomyopathy, Dilated (Treatment)

Association (NYHA) class IV symptoms and who were ill enough to have high priority for transplantation (United Network for Organ Sharing [UNOS] status 1A or 1B) who underwent implantation of HeartMate II LVAD for bridge to cardiac transplant, at 18-month follow-up, 79% underwent transplantation, LVAD removal for cardiac recovery, or had ongoing device support. [ ] The investigators reported significant functional status improvements and 6-minute walk test evident at 6 months, and an actuarial survival

2014 eMedicine.com

329. Cardioembolic Stroke (Treatment)

of cardioembolic stroke. The diagnosis is based on the triad of (1) identification of a potential cardiac source of embolism, (2) absence/exclusion of other potential sources of cerebral ischemia, and (3) consideration of clinical neurologic features, as described in Evaluation in Suspected Cardioembolic Stroke, above. Seizures and epilepsy should also be considered in the differential diagnosis. Previous Next: Recommended Tests Blood cultures If fever or leukocytosis is present, blood cultures for infective (...) of randomized controlled trials. Stroke . 2007 Feb. 38(2):423-30. . Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med . 2011 Sep 15. 365(11):981-92. . Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med . 2009 Sep 17. 361(12):1139-51. . Connolly SJ, Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S, et

2014 eMedicine.com

330. Atrial Fibrillation (Treatment)

mg than with warfarin; dabigatran 150 mg had similar bleeding to that of warfarin. [ , ] A meta-analysis by Uchino and Hernandez evaluated the risk of myocardial infarction or acute coronary syndrome (ACS) with the use of dabigatran. The results suggest the risk of myocardial infarction or ACS was similar when using revised RE-LY trial results. Dabigatran is associated with an increased risk of myocardial infarction or ACS in an extensive range of patients when tested against different controls (...) of intracranial bleeding Rapid onset and offset of action, with no need for bridging with parenteral anticoagulant therapy during initiation or after interruption No need for periodic INR testing Superiority to warfarin for reducing the risk of thromboembolic events with dabigatran 150 mg BID and apixaban Disadvantages of the newer oral anticoagulants include the following: Requires strict compliance, because missing even a single dose could result in a period without anticoagulation No FDA-approved reversal

2014 eMedicine.com

331. Erectile Dysfunction (Treatment)

. New agents are still undergoing clinical testing, and more are in the early phases of development. Medications currently being developed include dopaminergic and melanocortin receptor agonists, second-generation phosphodiesterase 5-inhibitors, rho-kinase inhibitors, soluble guanylate cyclases, and maxi-k channel activators. [ ] For any medication to be effective, the physiologic components involved in the erectile process must be functional. Serious impairments render the medication either (...) injection therapy is almost always effective. However, careful instruction in how to perform the injections is essential. The dosage is adjusted so as to achieve an erection with adequate rigidity for no more than 90 minutes. Alprostadil doses as high as 40 µg can be used. An abnormal finding after biothesiometry testing has been suggested as an indicator of possible heightened sensitivity to intracavernosal injections, but this suggestion remains unproven. The main adverse effects of intracavernosal

2014 eMedicine.com

332. Ptosis, Adult (Treatment)

. Evaluation and Management of Blepharoptosis . 1st. New York, NY: Springer-Verlag; 2010. Golnik KC, Pena R, Lee AG, Eggenberger ER. An ice test for the diagnosis of myasthenia gravis. Ophthalmology . 1999 Jul. 106(7):1282-6. . Glatt HJ, Fett DR, Putterman AM. Comparison of 2.5% and 10% phenylephrine in the elevation of upper eyelids with ptosis. Ophthalmic Surg . 1990 Mar. 21(3):173-6. . Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy . Philadelphia: WB Saunders; 1994. 120-5. Levine MR. Manual (...) . . Waqar S, McMurray C, Madge SN. Transcutaneous blepharoptosis surgery - advancement of levator aponeurosis. Open Ophthalmol J . Dec 2010. 14:4:76-80. . Baroody M, Holds JB, Sakamoto DK, Vick VL, Hartstein ME. Small incision transcutaneous levator aponeurotic repair for blepharoptosis. Ann Plast Surg . jun 2004. 52(6):558-561. . Park DH, Baik BS. Advancement of the Müller muscle-levator aponeurosis composite flap for correction of blepharoptosis. Plast Reconstr Surg . 2008 Jul. 122(1):140-2. . Dinges

2014 eMedicine.com

333. Hypertensive Heart Disease (Treatment)

, and monitoring the adverse effects of therapy. The tests to be ordered depend on clinical judgment regarding the etiology of hypertension. Recommendations from the Seventh Report of the Joint National Committee (JNC7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure include carrying out the following baseline laboratory workup before initiating treatment for hypertension [ ] : Electrocardiogram Urinalysis Blood glucose and hematocrit levels Serum potassium, creatinine (...) (or the corresponding estimated glomerular filtration rate [GFR]), and calcium measurements Lipid profile after a 9- to 12-hour fast - Includes high density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides Optional tests - Include measurement of urinary albumin excretion or albumin/creatinine ratio Cardiovascular risk assessment New guidelines on the assessment of cardiovascular risk, released in late 2013 by the American Heart Association/American College of Cardiology

2014 eMedicine.com

334. Medical Treatment of Stroke (Treatment)

activity for adults, as indicated in the 2008 Guidelines for Physical Activity Guidelines for Americans from the US Department of Health and Human Services, is to engage in at least 150 minutes (2 hours and 30 minutes) per week of moderate intensity or 75 minutes (1 hour and 15 minutes) per week of vigorous intensity aerobic physical activity. [ ] Obesity and body fat distribution Although no clinical trials have tested the effect of weight loss on stroke risk, numerous studies have examined (...) of acute treatment for CVT, and short or extended anticoagulant therapy is often used for secondary prevention after CVT, but no clinical trials have studied this use. Because new systemic venous thromboembolism is more common than recurrent CVT after CVT, it may be generally reasonable to prevent both by adopting venous thromboembolism prevention guidelines. However, the CVT statement recommends testing patients for prothrombotic conditions 2-4 weeks after completion of acute anticoagulant treatment

2014 eMedicine.com

335. Incontinence, Urinary: Nonsurgical Therapies (Treatment)

devices that seal the urethral meatus with an action similar to a suction cup. These devices can decrease significantly the urine loss in short-term pad test studies. In a more extended study of the device, only 2 of 31 women finished a 6-month trial. Reasons cited for dropout were lack of efficacy, poor adhesion, discomfort, and difficulty placing the device. This study points out that short-term results in highly motivated individuals may not be generalized to longer-term use under real-life (...) be suitable for men who wish to avoid surgery. [ ] For patients undergoing robot-assisted radical prostatectomy (RARP), a study by Lee et al found that the bladder plication stitch is an effective technical modification for lessening the period of recovery of urinary continence. [ ] Previous Next: Catheterization Urinary diversion, using various catheters, has been one of the mainstays of anti-incontinence therapy. The use of catheters for bladder drainage has withstood the test of time. Bladder

2014 eMedicine.com

336. Stroke Anticoagulation and Prophylaxis (Treatment)

) In patients with aortic atheromas identified on echocardiography, the ideal strategy for stroke prevention remains uncertain. Mixed outcomes have been reported for anticoagulation therapy; plaque stabilization with statins appears promising. Neither approach has been tested in randomized, controlled trials. [ ] Dissections of internal carotid and vertebral arteries The majority (85-95%) of ischemic symptoms after dissection of brain-supplying arteries are caused by emboli from the site of the dissection (...) anticoagulation to achieve a higher target INR (target INR, 2.5-3.5 or 3.0-4.0), switching from warfarin to therapeutic doses of unfractionated heparin or low-molecular weight heparin, or adding an antiplatelet agent to warfarin. [ ] Because the lupus anticoagulants may interfere with INR determination, monitoring these patients using the prothrombin-proconvertin time and the chromogenic factor-X assay would be preferable. However, these tests are expensive and are not widely available. Previous Next

2014 eMedicine.com

337. Heart Failure (Overview)

by the following four stages [ ] : Stage A: High risk of heart failure but no structural heart disease or symptoms of heart failure Stage B: Structural heart disease but no symptoms of heart failure Stage C: Structural heart disease and symptoms of heart failure Stage D: Refractory heart failure requiring specialized interventions Testing The following tests may be useful in the initial evaluation for suspected heart failure [ , , ] : Complete blood count (CBC) Iron studies Urinalysis Electrolyte levels Renal (...) and liver function studies Fasting blood glucose levels Lipid profile Thyroid stimulating hormone (TSH) levels B-type natriuretic peptide levels N-terminal pro-B-type natriuretic peptide levels Electrocardiography Chest radiography Two-dimensional (2-D) echocardiography Nuclear imaging [ ] Maximal exercise testing Pulse oximetry or arterial blood gas See for more detail. Management Treatment includes the following: Nonpharmacologic therapy: Oxygen and noninvasive positive pressure ventilation, dietary

2014 eMedicine.com

338. Diabetes Mellitus, Type 2 (Overview)

by the American Diabetes Association (ADA) include the following [ ] : A fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher, or A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75-g oral glucose tolerance test (OGTT), or A random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis Whether a hemoglobin A1c (HbA1c) level of 6.5% or higher should be a primary diagnostic criterion (...) therapy alone or with other agents if needed to maintain blood glucose control Where possible, all treatment decisions should involve the patient, with a focus on patient preferences, needs, and values A major focus on comprehensive cardiovascular risk reduction The 2013 ADA guidelines for SMBG frequency focus on an individual's specific situation rather than quantifying the number of tests that should be done. The recommendations include the following [ , ] : Patients on intensive insulin regimens

2014 eMedicine.com

339. Atrial Fibrillation (Overview)

Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med . 2011 Sep 8. 365 (10):883-91. . Granger CB, Alexander JH, McMurray JJ, et al, for the ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med . 2011 Sep 15. 365 (11):981-92. . . O’Riordan M. Consistent benefit of apixaban, even in patients at highest risk of bleeding: ARISTOTLE. Heartwire from Medscape. Available at . October 4, 2012; Accessed: October 15

2014 eMedicine.com

340. Incontinence, Urinary: Nonsurgical Therapies (Follow-up)

devices that seal the urethral meatus with an action similar to a suction cup. These devices can decrease significantly the urine loss in short-term pad test studies. In a more extended study of the device, only 2 of 31 women finished a 6-month trial. Reasons cited for dropout were lack of efficacy, poor adhesion, discomfort, and difficulty placing the device. This study points out that short-term results in highly motivated individuals may not be generalized to longer-term use under real-life (...) be suitable for men who wish to avoid surgery. [ ] For patients undergoing robot-assisted radical prostatectomy (RARP), a study by Lee et al found that the bladder plication stitch is an effective technical modification for lessening the period of recovery of urinary continence. [ ] Previous Next: Catheterization Urinary diversion, using various catheters, has been one of the mainstays of anti-incontinence therapy. The use of catheters for bladder drainage has withstood the test of time. Bladder

2014 eMedicine.com

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