NEJM â Collection Updates for Cardiovascular Diseases

CLINICAL PROBLEM-SOLVING: Under Pressure

Thu, 04Â FebÂ 2010 00:00:00 -05:00

A 25-year-old woman presented to her local hospital with dyspnea. She described a 2-year history of progressive shortness of breath on exertion. One year earlier she was able to walk...

IMAGES IN CLINICAL MEDICINE: Kinked Carotids

Robert L. Rosenthal, M.D. and Bradley R. Grimsley, M.D. — Thu, 04Â FebÂ 2010 00:00:00 -05:00

An 80-year-old woman presented with congestive heart failure due to aortic insufficiency associated with a markedly dilated ascending aorta. On physical examination, she was noted to have a pulsatile mass...

CORRESPONDENCE: Lovastatin in X-Linked Adrenoleukodystrophy

Thu, 21Â JanÂ 2010 00:00:00 -05:00

To the Editor: As reported previously in the Journal, lovastatin lowers levels of very-long-chain fatty acids in plasma in patients with X-linked adrenoleukodystrophy (X-ALD).1 Further studies did not reproduce this...

EDITORIAL: The Shrinking Heart in Chronic Obstructive Pulmonary Disease

Anton Vonk-Noordegraaf, M.D. — Thu, 21Â JanÂ 2010 00:00:00 -05:00

In patients with emphysema, the cardiac silhouette on the radiograph is typically long and narrow. The common explanation for this finding is the altered, more vertical position of the heart...

REVIEW ARTICLE: WilliamsâBeuren Syndrome

Barbara R. Pober, M.D. — Thu, 21Â JanÂ 2010 00:00:00 -05:00

WilliamsâBeuren syndrome (also known as Williams' syndrome; Online Mendelian Inheritance in Man [OMIM] number, 194050), a multisystem disorder, is caused by deletion of the WilliamsâBeuren syndrome chromosome region, spanning 1.5...

ORIGINAL ARTICLE: Percent Emphysema, Airflow Obstruction, and Impaired Left Ventricular Filling

Thu, 21Â JanÂ 2010 00:00:00 -05:00

Background: Very severe chronic obstructive pulmonary disease causes cor pulmonale with elevated pulmonary vascular resistance and secondary reductions in left ventricular filling, stroke volume, and cardiac output. We hypothesized that...

CLINICAL PROBLEM-SOLVING: Painful Purple Toes

Thu, 07Â JanÂ 2010 00:00:00 -05:00

A 57-year-old man presented to the emergency department with painful purple toes. On the day of presentation, he had first been seen in another hospital but left against medical advice...

IMAGES IN CLINICAL MEDICINE: Giant Abdominal Aortic Aneurysm

James L. Ebaugh, M.D. and Joseph D. Raffetto, M.D. — Thu, 07Â JanÂ 2010 00:00:00 -05:00

A 74-year-old man presented to his outpatient physician after noticing a painless, visible abdominal mass 3 weeks earlier (Panel A). His medical history was significant for 40 pack-years of smoking...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 41-2009 â A 16-Year-Old Boy with Hypothermia and Frostbite

Thu, 31Â DecÂ 2009 00:00:00 -05:00

Dr. Benjamin Sandefur (Emergency Medicine): A 16-year-old boy was admitted to the hospital after being found unconscious in a snow bank at 6 a.m. on New Year's Day. He had...

IMAGES IN CLINICAL MEDICINE: Vanishing Mediastinal Mass

Marc de Perrot, M.D. and Yaron Shargall, M.D. — Thu, 31Â DecÂ 2009 00:00:00 -05:00

A 39-year-old man with no notable medical history was being examined because of a transient ischemic attack. On a chest radiograph, a mediastinal mass was detected when the patient was...

ORIGINAL ARTICLE: Long-Term Outcome Associated with Early Repolarization on Electrocardiography

Thu, 24Â DecÂ 2009 00:00:00 -05:00

Background: Early repolarization, which is characterized by an elevation of the QRSâST junction (J point) in leads other than V1 through V3 on 12-lead electrocardiography, has been associated with vulnerability...

INTERACTIVE MEDICAL CASE: Painful Purple Toes

Thu, 17Â DecÂ 2009 00:00:00 -05:00

A 57-year-old man presented to the emergency department with painful purple toes. He had first noted pain and discoloration in his left great toe 2 weeks earlier. One week before...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 39-2009 â A 28-Year-Old Pregnant Woman with Acute Cardiac Failure

Thu, 17Â DecÂ 2009 00:00:00 -05:00

Dr. Brad W. Butcher (Medicine): A 28-year-old woman was admitted to this hospital 2 days post partum because of cardiac failure.

The patient had been well, except for gestational diabetes mellitus,...

EDITORIAL: Cangrelor â A Champion Lost in Translation?

Adnan Kastrati, M.D., and Gjin Ndrepepa, M.D. — Thu, 10Â DecÂ 2009 00:00:00 -05:00

Current guidelines recommend the early use of drugs that block platelet adenosine diphosphate (ADP) receptor P2Y12 in patients with acute coronary syndromes in whom percutaneous coronary intervention (PCI) may be...

IMAGES IN CLINICAL MEDICINE: Blurred Vision after Cardiac Catheterization

Carsten H. Meyer, M.D. and Frank G. Holz, M.D. — Thu, 10Â DecÂ 2009 00:00:00 -05:00

A 56-year-old woman with hypertension presented with a sudden onset of painless impaired vision in the right eye. On the previous day, she had undergone cardiac catheterization for evaluation of...

ORIGINAL ARTICLE: Intravenous Platelet Blockade with Cangrelor during PCI

Thu, 10Â DecÂ 2009 00:00:00 -05:00

Background: Intravenous cangrelor, a rapid-acting, reversible adenosine diphosphate (ADP) receptor antagonist, might reduce ischemic events during percutaneous coronary intervention (PCI).

Methods: In this double-blind, placebo-controlled study, we randomly assigned 5362 patients...

ORIGINAL ARTICLE: Platelet Inhibition with Cangrelor in Patients Undergoing PCI

Thu, 10Â DecÂ 2009 00:00:00 -05:00

Background: Cangrelor, a nonthienopyridine adenosine triphosphate analogue, is an intravenous blocker of the adenosine diphosphate receptor P2Y12. This agent might have a role in the treatment of patients who require...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: A Look at the Low-Carbohydrate Diet

Steven R. Smith, M.D. — Thu, 03Â DecÂ 2009 00:00:00 -05:00

Most fad diets are just that â a bright flash that quickly fades, only to be followed by another best-seller and a new face on the talk-show circuit. The high-fat,...

CLINICAL PROBLEM-SOLVING: A Crisis in Late Pregnancy

Thu, 03Â DecÂ 2009 00:00:00 -05:00

A 31-year-old woman in the 37th week of an uncomplicated pregnancy presented to the emergency department with sudden onset of severe bitemporal headache and shortness of breath. Her medical history...

CLINICAL THERAPEUTICS: Mitral-Valve Repair for Mitral-Valve Prolapse

Subodh Verma, M.D., Ph.D., and Thierry G. Mesana, M.D., Ph.D. — Thu, 03Â DecÂ 2009 00:00:00 -05:00

A 55-year-old man with a holosystolic murmur of increasing intensity has been seen regularly by his family physician for the past 3 years. He is referred to a cardiologist. The...

IMAGES IN CLINICAL MEDICINE: Large Atrial Myxoma

Aman Mundi, M.D. — Thu, 26Â NovÂ 2009 00:00:00 -05:00

A 57-year-old woman with no notable medical history presented with a 4-month history of leg swelling and dyspnea on exertion. Her symptoms had been progressively worsening for 2 weeks before...

EDITORIAL: Deleterious Effects of Right Ventricular Pacing

Bruce D. Lindsay, M.D. — Thu, 26Â NovÂ 2009 00:00:00 -05:00

In this issue of the Journal, Yu et al. report results of the Pacing to Avoid Cardiac Enlargement (PACE) study, a prospective, double-blind, multicenter trial designed to determine whether biventricular...

EDITORIAL: Statin Therapy with Ezetimibe or Niacin in High-Risk Patients

John J.P. Kastelein, M.D., Ph.D., and Michiel L. Bots, M.D., Ph.D. — Thu, 26Â NovÂ 2009 00:00:00 -05:00

The use of statin therapy to reduce levels of low-density lipoprotein (LDL) cholesterol in patients who are at high risk for vascular events results in a 30 to 40% reduction...

EDITORIAL: The HALTS Trial â Halting Atherosclerosis or Halted Too Early?

Roger S. Blumenthal, M.D., and Erin D. Michos, M.D., M.H.S. — Thu, 26Â NovÂ 2009 00:00:00 -05:00

In patients with elevated cholesterol levels, statin therapy reduces the incidence of cardiovascular events by 25 to 45%. Despite the administration of a statin, many patients require additional lipid-lowering therapy...

ORIGINAL ARTICLE: Biventricular Pacing in Patients with Bradycardia and Normal Ejection Fraction

Thu, 26Â NovÂ 2009 00:00:00 -05:00

Background: Observational studies suggest that conventional right ventricular apical pacing may have a deleterious effect on left ventricular function. In this study, we examined whether biventricular pacing is superior to...

ORIGINAL ARTICLE: Extended-Release Niacin or Ezetimibe and Carotid IntimaâMedia Thickness

Thu, 26Â NovÂ 2009 00:00:00 -05:00

Background: Treatment added to statin monotherapy to further modify the lipid profile may include combination therapy to either raise the high-density lipoprotein (HDL) cholesterol level or further lower the low-density...

EDITORIAL: Treatment of Anemia in Chronic Kidney Disease â Strategies Based on Evidence

Philip A. Marsden, M.D. — Thu, 19Â NovÂ 2009 00:00:00 -05:00

Anemia associated with chronic kidney disease and end-stage renal disease is due, in large part, to reduced production of renal erythropoietin and abnormalities in extracellular-fluid volume homeostasis.1 Moreover, anemia and...

ORIGINAL ARTICLE: A Trial of Darbepoetin Alfa in Type 2 Diabetes and Chronic Kidney Disease

Thu, 19Â NovÂ 2009 00:00:00 -05:00

Background: Anemia is associated with an increased risk of cardiovascular and renal events among patients with type 2 diabetes and chronic kidney disease. Although darbepoetin alfa can effectively increase hemoglobin...

CLINICAL PRACTICE: Renal-Artery Stenosis

Lance D. Dworkin, M.D., and Christopher J. Cooper, M.D. — Thu, 12Â NovÂ 2009 00:00:00 -05:00

A 73-year-old former smoker with a history of hypertension and dyslipidemia presents to the emergency department with shortness of breath. His blood pressure is 160/75 mm Hg, heart rate 60...

ORIGINAL ARTICLE: Revascularization versus Medical Therapy for Renal-Artery Stenosis

The ASTRAL Investigators — Thu, 12Â NovÂ 2009 00:00:00 -05:00

Background: Percutaneous revascularization of the renal arteries improves patency in atherosclerotic renovascular disease, yet evidence of a clinical benefit is limited.

Methods: In a randomized, unblinded trial, we assigned 806 patients...

VIDEOS IN CLINICAL MEDICINE: AnkleâBrachial Index for Assessment of Peripheral Arterial Disease

S. Marlene Grenon, M.D.C.M., Joel Gagnon, M.D., and York Hsiang, M.D. — Thu, 05Â NovÂ 2009 00:00:00 -05:00

...

EDITORIAL: Innovation and Comparative-Effectiveness Research in Cardiac Surgery

Eric David Peterson, M.D., M.P.H. — Thu, 05Â NovÂ 2009 00:00:00 -05:00

Cardiac surgery has always been a unique combination of art and science. The field is advanced by those who push the envelope by suggesting innovations. Yet promising techniques need to...

CLINICAL THERAPEUTICS: Phosphodiesterase Type 5 Inhibitors for Pulmonary Arterial Hypertension

Stephen L. Archer, M.D., and Evangelos D. Michelakis, M.D. — Thu, 05Â NovÂ 2009 00:00:00 -05:00

A 46-year-old woman presents with progressive exertional dyspnea and recurrent exertional syncope. Her jugular venous pressure is 16 cm of water, and moderate peripheral edema is noted. Auscultation reveals a...

ORIGINAL ARTICLE: On-Pump versus Off-Pump Coronary-Artery Bypass Surgery

Thu, 05Â NovÂ 2009 00:00:00 -05:00

Background: Coronary-artery bypass grafting (CABG) has traditionally been performed with the use of cardiopulmonary bypass (on-pump CABG). CABG without cardiopulmonary bypass (off-pump CABG) might reduce the number of complications related...

IMAGES IN CLINICAL MEDICINE: A Swinging Heart

John R. Kapoor, M.D., Ph.D. and Michael V. McConnell, M.D. — Thu, 29Â OctÂ 2009 00:00:00 -05:00

A 39-year-old woman with a 1-year history of Stage IV melanoma presented with progressive shortness of breath, fatigue, and edema in the legs, which had developed over the course of...

EDITORIAL: Blood-Pressure Control and Delay in Progression of Kidney Disease in Children

Julie R. Ingelfinger, M.D. — Thu, 22Â OctÂ 2009 00:00:00 -05:00

Many children with chronic kidney disease, even those in whom the disease is discovered very early, ultimately lose renal function; some ultimately progress to stage 5 chronic kidney disease (end-stage...

ORIGINAL ARTICLE: Strict Blood-Pressure Control and Progression of Renal Failure in Children

The ESCAPE Trial Group — Thu, 22Â OctÂ 2009 00:00:00 -05:00

Background: Although inhibition of the reninâangiotensin system delays the progression of renal failure in adults with chronic kidney disease, the blood-pressure target for optimal renal protection is controversial. We assessed...

EDITORIAL: The Confirmatory Trial in Comparative-Effectiveness Research

Alan M. Garber, M.D., Ph.D., and Mark A. Hlatky, M.D. — Thu, 08Â OctÂ 2009 00:00:00 -05:00

Despite the infusion of more than $1 billion through the American Recovery and Reinvestment Act of 2009 and the potential commitment of much more money, there will never be enough...

ORIGINAL ARTICLE: Defibrillator Implantation Early after Myocardial Infarction

Thu, 08Â OctÂ 2009 00:00:00 -05:00

Background: The rate of death, including sudden cardiac death, is highest early after a myocardial infarction. Yet current guidelines do not recommend the use of an implantable cardioverterâdefibrillator (ICD) within...

IMAGES IN CLINICAL MEDICINE: Pericardial Calcification Noted Long after Sydenham's Chorea

R. Arthur Bouwman, M.D., Ph.D. and Rob J.M. Strack van Schijndel, M.D. — Thu, 01Â OctÂ 2009 00:00:00 -05:00

A 76-year-old native Dutch woman was admitted to our intensive care unit for hemodynamic monitoring after undergoing vulvectomy and inguinal lymph-node dissection for vulvar carcinoma. Preoperative evaluation had revealed a...

EDITORIAL: Can We Rely on RE-LY?

Brian F. Gage, M.D. — Thu, 17Â SepÂ 2009 00:00:00 -05:00

In patients with atrial fibrillation, warfarin prevents 64% of strokes.1 Thus, warfarin has become the recommended treatment for candidates for anticoagulation therapy who have atrial fibrillation and at least one...

ORIGINAL ARTICLE: Dabigatran versus Warfarin in Patients with Atrial Fibrillation

Thu, 17Â SepÂ 2009 00:00:00 -05:00

Background: Warfarin reduces the risk of stroke in patients with atrial fibrillation but increases the risk of hemorrhage and is difficult to use. Dabigatran is a new oral direct thrombin...

CORRESPONDENCE: Ruptured Abdominal Aortic Aneurysm Related to IgG4 Periaortitis

Qi Qian, M.D., Kianoush B. Kashani, M.D., and Dylan V. Miller, M.D. — Thu, 10Â SepÂ 2009 00:00:00 -05:00

To the Editor: Periaortitis that is associated with immunoglobulin G4 (IgG4) plasma-cell infiltration is a rare condition with undefined incidence and clinical features. In a single-center study in Japan, the...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Understanding Abdominal Aortic Aneurysm

Neal L. Weintraub, M.D. — Thu, 10Â SepÂ 2009 00:00:00 -05:00

Abdominal aortic aneurysms occur in up to 9% of adults older than 65 years of age, and the rupture of these aneurysms accounts for about 15,000 deaths in the United...

CLINICAL PRACTICE: Should Coronary Calcium Screening Be Used in Cardiovascular Prevention Strategies?

Robert O. Bonow, M.D. — Thu, 03Â SepÂ 2009 00:00:00 -05:00

A 52-year-old man requests a coronary-artery calcium (CAC) scan for assessment of his risk of coronary events after seeing an advertisement from a local facility that offers the test. He...

ORIGINAL ARTICLE: Fluvastatin and Perioperative Events in Patients Undergoing Vascular Surgery

Thu, 03Â SepÂ 2009 00:00:00 -05:00

Background: Adverse cardiac events are common after vascular surgery. We hypothesized that perioperative statin therapy would improve postoperative outcomes.

Methods: In this double-blind, placebo-controlled trial, we randomly assigned patients who had...

CLINICAL PROBLEM-SOLVING: A Change of Heart

Thu, 03Â SepÂ 2009 00:00:00 -05:00

A 57-year-old teacher with a history of hypertension presented to an urgent care center with nonradiating chest pressure and light-headedness. The chest pressure had begun soon after she arrived at...

EDITORIAL: Clinical Application of Sensitive Troponin Assays

David A. Morrow, M.D., M.P.H. — Thu, 27Â AugÂ 2009 00:00:00 -05:00

Despite the pervasive measurement of cardiac troponin for the diagnosis of myocardial infarction, the continued evolution of assays and guidelines for their application has created uncertainty among many practitioners regarding...

ORIGINAL ARTICLE: Sensitive Troponin I Assay in Early Diagnosis of Acute Myocardial Infarction

Thu, 27Â AugÂ 2009 00:00:00 -05:00

Background: Cardiac troponin testing is central to the diagnosis of acute myocardial infarction. We evaluated a sensitive troponin I assay for the early diagnosis and risk stratification of myocardial infarction.

Methods:...

ORIGINAL ARTICLE: Early Diagnosis of Myocardial Infarction with Sensitive Cardiac Troponin Assays

Thu, 27Â AugÂ 2009 00:00:00 -05:00

Background: The rapid and reliable diagnosis of acute myocardial infarction is a major unmet clinical need.

Methods: We conducted a multicenter study to examine the diagnostic accuracy of new, sensitive cardiac...

SPECIAL REPORT: Premature Release of Data from Clinical Trials of Ezetimibe

Robert M. Califf, M.D., Robert A. Harrington, M.D., and Michael A. Blazing, M.D. — Thu, 13Â AugÂ 2009 00:00:00 -05:00

The recent controversy about whether the cholesterol-lowering drug ezetimibe causes cancer raises urgent questions about the systems we use to develop drugs and medical devices and then to evaluate their...

CLINICAL PRACTICE: Neurologic Prognosis after Cardiac Arrest

G. Bryan Young, M.D. — Thu, 06Â AugÂ 2009 00:00:00 -05:00

A 55-year-old man collapses while jogging through the park. A bystander finds him unconscious and without a pulse and initiates cardiopulmonary resuscitation (CPR) while an ambulance is summoned. On arrival...

IMAGES IN CLINICAL MEDICINE: Asymmetric Edema of the Upper Lung Due to Mitral Valvular Dysfunction

Siva Raman, M.D. and Sudhakar Pipavath, M.D. — Thu, 30Â JulÂ 2009 00:00:00 -05:00

An 80-year-old woman with chronic obstructive pulmonary disease and mitral-valve prolapse presented with progressive dyspnea, orthopnea, and dry cough, which she reported having had for the previous 3 days. She...

IMAGES IN CLINICAL MEDICINE: Pneumopericardium and Pneumothorax

Jason Andrade, M.D. and Eve Aymong, M.D. — Thu, 30Â JulÂ 2009 00:00:00 -05:00

A 60-year old man presented with progressive dyspnea 3 months after undergoing uncomplicated aortic-valve replacement and mitral-valve repair for valvular insufficiency related to previous endocarditis. A chest radiograph obtained on...

BOOK REVIEW:

Thu, 09Â JulÂ 2009 00:00:00 -05:00

The vascular endothelium is a metabolically active organ system that helps regulate cardiovascular homeostasis. In addition to being an anatomical barrier that prevents the influx of circulating blood into the...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Cardiomyocyte Renewal

Michael S. Parmacek, M.D., and Jonathan A. Epstein, M.D. — Thu, 02Â JulÂ 2009 00:00:00 -05:00

The capacity of the heart to regenerate functional myocardium is extremely limited or absent. This lack of regenerative capacity contrasts with that of many other organs and tissues. Heart failure...

ORIGINAL ARTICLE: Epidemiologic Study of In-Hospital Cardiopulmonary Resuscitation in the Elderly

Thu, 02Â JulÂ 2009 00:00:00 -05:00

Background: It is unknown whether the rate of survival after in-hospital cardiopulmonary resuscitation (CPR) is improving and which characteristics of patients and hospitals predict survival.

Methods: We examined fee-for-service Medicare data...

EDITORIAL: Routine Angioplasty after Fibrinolysis â How Early Should âEarlyâ Be?

Freek W.A. Verheugt, M.D. — Thu, 25Â JunÂ 2009 00:00:00 -05:00

Reperfusion therapy has represented a great leap forward in the management of myocardial infarction with ST-segment elevation. Its goal is early and complete recanalization of the infarct-related artery to salvage...

ORIGINAL ARTICLE: Routine Early Angioplasty after Fibrinolysis for Acute Myocardial Infarction

Thu, 25Â JunÂ 2009 00:00:00 -05:00

Background: Patients with a myocardial infarction with ST-segment elevation who present to hospitals that do not have the capability of performing percutaneous coronary intervention (PCI) often cannot undergo timely primary...

CLINICAL PRACTICE: Chronic Venous Insufficiency and Varicose Veins

Seshadri Raju, M.D., and Peter NeglÃ©n, M.D., Ph.D. — Thu, 28Â MayÂ 2009 00:00:00 -05:00

A 52-year-old receptionist presents with an ulcer on her ankle that has persisted for a year. The use of narcotic analgesics once or twice a day and elevation of the...

CLINICAL PROBLEM-SOLVING: A Red Flag

Thu, 07Â MayÂ 2009 00:00:00 -05:00

A 64-year-old man was brought to the emergency department because of sudden-onset blurred vision in both eyes and diplopia, as well as a frontal headache that had begun earlier that...

IMAGES IN CLINICAL MEDICINE: Abdominal Aortic Aneurysm

Mohammed Al-Omran, M.D. and Badr Aljabri, M.D. — Thu, 07Â MayÂ 2009 00:00:00 -05:00

A 76-year-old man presented with mild back pain of 2 weeks' duration. The physical examination revealed a blood pressure of 140/85 mm Hg and a pulsatile, nontender abdominal mass (Panel...

IMAGES IN CLINICAL MEDICINE: Familial Hypercholesterolemia

Sheng Guang Li, M.D. — Thu, 30Â AprÂ 2009 00:00:00 -05:00

An 18-year-old woman with familial hypercholesterolemia presented with a 4-year history of swelling and pain in the joints. She was born with multiple xanthomas, which grew in size as she...

IMAGES IN CLINICAL MEDICINE: Pulmonary Arteriovenous Fistula

Nils Kraemer, M.D. and Gabriele A. Krombach, M.D. — Thu, 23Â AprÂ 2009 00:00:00 -05:00

A 50-year-old woman presented with mild exercise-induced shortness of breath; she reported being otherwise healthy. Her family history was notable for her mother's having the OslerâWeberâRendu syndrome, also called hereditary...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Limiting Fibrosis after Myocardial Infarction

Bodh I. Jugdutt, M.D., D.M. — Thu, 09Â AprÂ 2009 00:00:00 -05:00

A recent study by Kobayashi and colleagues1 showed that a secreted protein may be a therapeutic target for limiting fibrosis and improving function after myocardial infarction. Myocardial infarction is a...

IMAGES IN CLINICAL MEDICINE: Kerley's A, B, and C Lines

Takeharu Koga, M.D., Ph.D. and Kiminori Fujimoto, M.D., Ph.D. — Thu, 09Â AprÂ 2009 00:00:00 -05:00

A 59-year-old woman with hypertension and diabetic nephropathy presented with a sudden onset of dyspnea after discontinuing her medications. Physical examination revealed hypertension (blood pressure, 225/122 mm Hg), tachycardia (heart...

EDITORIAL: Sunset for Statins after AURORA?

Giovanni F.M. Strippoli, Ph.D., and Jonathan C. Craig, Ph.D. — Thu, 02Â AprÂ 2009 00:00:00 -05:00

Reducing mortality from cardiovascular disease among patients undergoing dialysis is a global public health challenge. The past 10 years have seen trials of many interventions designed to improve survival and...

REVIEW ARTICLE: Medical Evaluation of Patients Undergoing Electroconvulsive Therapy

Anjala V. Tess, M.D., and Gerald W. Smetana, M.D. — Thu, 02Â AprÂ 2009 00:00:00 -05:00

After a period of declining use, electroconvulsive therapy (ECT) is now used more widely as a treatment for major depression and other psychiatric disorders.1 Many patients undergoing ECT are elderly...

ORIGINAL ARTICLE: Rosuvastatin and Cardiovascular Events in Patients Undergoing Hemodialysis

Thu, 02Â AprÂ 2009 00:00:00 -05:00

Background: Statins reduce the incidence of cardiovascular events in patients at high cardiovascular risk. However, a benefit of statins in such patients who are undergoing hemodialysis has not been proved.

Methods:...

REVIEW ARTICLE: Moyamoya Disease and Moyamoya Syndrome

R. Michael Scott, M.D., and Edward R. Smith, M.D. — Thu, 19Â MarÂ 2009 00:00:00 -05:00

The moyamoya syndrome is a cerebrovascular condition that predisposes affected patients to stroke in association with progressive stenosis of the intracranial internal carotid arteries and their proximal branches. Reduced blood...

PERSPECTIVE: Eliminating Racial and Ethnic Disparities in Cardiac Care

Thu, 19Â MarÂ 2009 00:00:00 -05:00

The Institute of Medicine (IOM) includes âequityâ as one of six key domains of health care quality, yet equal treatment for Americans of all races and ethnic groups remains an...

PERSPECTIVE: An Uncertain Future for Cardiovascular Drug Development?

Thu, 19Â MarÂ 2009 00:00:00 -05:00

The past year has been a challenging one for Pfizer, the world's largest pharmaceutical company. Its stock price has fallen as it has struggled to boost research productivity, going so...

IMAGES IN CLINICAL MEDICINE: Venous Obstruction of the Thigh

Alberto Caggiati, M.D. and Carlo Catalano, M.D. — Thu, 12Â MarÂ 2009 00:00:00 -05:00

A 56-year-old man presented with a post-thrombotic syndrome of the left leg (involving edema, varicose veins, trophic skin changes, and an ulcer, 5 cm in diameter, of the distal medial...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Reversing Atherosclerosis?

Linda K. Curtiss, Ph.D. — Thu, 12Â MarÂ 2009 00:00:00 -05:00

Atherosclerosis is reversible and involves the removal of trapped cholesterol-loaded foam-cell macrophages from the arterial intima. A recent study by Park and colleagues1 showed that these foam cells are trapped...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 8-2009 â A 36-Year-Old Woman with Headache, Hypertension, and Seizure 2 Weeks Post Partum

Thu, 12Â MarÂ 2009 00:00:00 -05:00

Dr. W. Taylor Kimberly: A 36-year-old woman was admitted to the hospital because of headaches, hypertension, and seizures.

Nineteen days before the current admission, she delivered healthy twins at 35.6 weeks...

CLINICAL PROBLEM-SOLVING: When Past Is Prologue

Thu, 05Â MarÂ 2009 00:00:00 -05:00

A 36-year-old man presented to the emergency department with a 2-week history of lower-extremity edema, progressive fatigue, and exertional dyspnea. The patient's medical history was notable for a fall from...

ORIGINAL ARTICLE: Quality of Life after Late Invasive Therapy for Occluded Arteries

Thu, 19Â FebÂ 2009 00:00:00 -05:00

Background: The open-artery hypothesis postulates that late opening of an infarct-related artery after myocardial infarction will improve clinical outcomes. We evaluated the quality-of-life and economic outcomes associated with the use...

VIDEOS IN CLINICAL MEDICINE: Blood-Pressure Measurement

Thu, 29Â JanÂ 2009 00:00:00 -05:00

...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Getting to the Heart of Proteomics

Peipei Ping, Ph.D. — Thu, 29Â JanÂ 2009 00:00:00 -05:00

Chen and colleagues1 recently described mitochondrial aldehyde dehydrogenase type 2 (ALDH2) as a target in protecting the heart against ischemic insult. Their study provides insights into cardiovascular biology and may...

IMAGES IN CLINICAL MEDICINE: Metallic Mercury Embolism to the Hand

Antonio Carlos de Souza and Adelino Moreira de Carvalho, M.D., M.Sc., Ph.D. — Thu, 29Â JanÂ 2009 00:00:00 -05:00

Severe pain developed in the left hand of a 46-year-old woman after open heart surgery was performed to repair an atrial septal defect. It was initially thought that this pain...

BOOK REVIEW:

Thu, 22Â JanÂ 2009 00:00:00 -05:00

Pioneers of Cardiac Surgery has two principal parts, which are complementary and cohesive visions of the history of surgical pioneers. The first part is a short description of the development...

EDITORIAL: Clopidogrel, Genetics, and Drug Responsiveness

Jane E. Freedman, M.D., and Elaine M. Hylek, M.D., M.P.H. — Thu, 22Â JanÂ 2009 00:00:00 -05:00

Despite great progress in the diagnosis and treatment of unstable coronary syndromes, it is estimated that 785,000 Americans will have new acute cardiac events and 470,000 will have recurrent events...

ORIGINAL ARTICLE: Genetic Determinants of Response to Clopidogrel and Cardiovascular Events

Thu, 22Â JanÂ 2009 00:00:00 -05:00

Background: Pharmacogenetic determinants of the response of patients to clopidogrel contribute to variability in the biologic antiplatelet activity of the drug. The effect of these determinants on clinical outcomes after...

ORIGINAL ARTICLE: Cytochrome P-450 Polymorphisms and Response to Clopidogrel

Thu, 22Â JanÂ 2009 00:00:00 -05:00

Background: Clopidogrel requires transformation into an active metabolite by cytochrome P-450 (CYP) enzymes for its antiplatelet effect. The genes encoding CYP enzymes are polymorphic, with common alleles conferring reduced function.

Methods:...

CORRESPONDENCE: Long-QT Syndrome Induced by the Antiaddiction Drug Ibogaine

Thu, 15Â JanÂ 2009 00:00:00 -05:00

To the Editor: Anecdotal evidence suggests that ibogaine alleviates drug craving and relapse of drug use in humans, as has been confirmed for animals.1 Ibogaine is currently used as an...

EDITORIAL: Antipsychotic Agents and Sudden Cardiac Death â How Should We Manage the Risk?

Sebastian Schneeweiss, M.D., Sc.D., and Jerry Avorn, M.D. — Thu, 15Â JanÂ 2009 00:00:00 -05:00

Antipsychotic medications are commonly used across the entire age spectrum, both within and outside their labeled (and evidence-based) indications.12 Three atypical antipsychotic medications, olanzapine (Zyprexa, Eli Lilly), risperidone (Risperdal, Janssen),...

ORIGINAL ARTICLE: Atypical Antipsychotic Drugs and the Risk of Sudden Cardiac Death

Thu, 15Â JanÂ 2009 00:00:00 -05:00

Background: Users of typical antipsychotic drugs have an increased risk of serious ventricular arrhythmias and sudden cardiac death. However, less is known regarding the cardiac safety of the atypical antipsychotic...

SPECIAL ARTICLE: Mortality Attributable to Smoking in China

Thu, 08Â JanÂ 2009 00:00:00 -05:00

Background: Smoking is a risk factor for many diseases and has been increasingly prevalent in economically developing regions of the world. We aimed to estimate the number of deaths attributable...

ORIGINAL ARTICLE: Glucose Control and Vascular Complications in Veterans with Type 2 Diabetes

Thu, 08Â JanÂ 2009 00:00:00 -05:00

Background: The effects of intensive glucose control on cardiovascular events in patients with long-standing type 2 diabetes mellitus remain uncertain.

Methods: We randomly assigned 1791 military veterans (mean age, 60.4 years)...

ORIGINAL ARTICLE: Modulation of Blood Pressure by Central Melanocortinergic Pathways

Thu, 01Â JanÂ 2009 00:00:00 -05:00

Background: Weight gain and weight loss are associated with changes in blood pressure through unknown mechanisms. Central melanocortinergic signaling is implicated in the control of energy balance and blood pressure...

ORIGINAL ARTICLE: A Syndrome with Congenital Neutropenia and Mutations in

Thu, 01Â JanÂ 2009 00:00:00 -05:00

Background: The main features of severe congenital neutropenia are the onset of severe bacterial infections early in life, a paucity of mature neutrophils, and an increased risk of leukemia. In...

PERSPECTIVE: The Many Causes of Severe Congenital Neutropenia

Thu, 01Â JanÂ 2009 00:00:00 -05:00

In 1956, Rolf Kostmann, a Swedish pediatrician, described an autosomal recessive disorder that he called infantile genetic agranulocytosis â which is now called severe congenital neutropenia. The Kostmann form of...

CLINICAL PRACTICE: Acute Pulmonary Embolism

Stavros Konstantinides, M.D. — Thu, 25Â DecÂ 2008 00:00:00 -05:00

A 62-year-old man presented with a 5-day history of progressively worsening dyspnea and orthopnea after returning from a 3-day business trip to the Far East. On physical examination, the heart...

ORIGINAL ARTICLE: Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest

Thu, 18Â DecÂ 2008 00:00:00 -05:00

Background: Approximately 70% of persons who have an out-of-hospital cardiac arrest have underlying acute myocardial infarction or pulmonary embolism. Therefore, thrombolysis during cardiopulmonary resuscitation may improve survival.

Methods: In a double-blind,...

PERSPECTIVE: Learning from Our Mistakes? Testing New ICD Technology

Thu, 11Â DecÂ 2008 00:00:00 -05:00

More than 160,000 implantable cardioverterâdefibrillators (ICDs) are implanted annually in the United States to prevent sudden death from cardiac causes in high-risk patients. Recently, concerns have been raised about the...

EDITORIAL: Does It Matter How Hypertension Is Controlled?

Aram V. Chobanian, M.D. — Thu, 04Â DecÂ 2008 00:00:00 -05:00

Hypertension is one of the most important risk factors for cardiovascular and renal diseases. Currently, approximately 73 million adults in the United States and approximately 1 billion adults worldwide have...

CLINICAL PROBLEM-SOLVING: Taken Out of Context

Michael P. Thomas, M.D., and Andrew Wang, M.D. — Thu, 04Â DecÂ 2008 00:00:00 -05:00

A 25-year-old woman with a history of depression, mitral-valve prolapse, and migraine headaches presented to a hospital emergency department with a 3-day history of subjective fever, diffuse arthralgia, and severe...

ORIGINAL ARTICLE: Benazepril plus Amlodipine or Hydrochlorothiazide for Hypertension in High-Risk Patients

Thu, 04Â DecÂ 2008 00:00:00 -05:00

Background: The optimal combination drug therapy for hypertension is not established, although current U.S. guidelines recommend inclusion of a diuretic. We hypothesized that treatment with the combination of an angiotensin-convertingâenzyme...

CORRESPONDENCE: Triglyceride Deposit Cardiomyovasculopathy

Thu, 27Â NovÂ 2008 00:00:00 -05:00

To the Editor: A 41-year-old man was admitted to our hospital with ventricular tachycardia in 2003. Biopsy specimens obtained from the right ventricle showed neutral lipid deposition in cardiomyocytes. In...

PERSPECTIVE: Pay Now, Benefits May Follow â The Case of Cardiac Computed Tomographic Angiography

Thu, 27Â NovÂ 2008 00:00:00 -05:00

The average American might assume that new medical procedures are proved beneficial before insurers pay for them. In reality, many new procedures are paid for even with no persuasive evidence...

IMAGES IN CLINICAL MEDICINE: Recurrent Aspiration Pneumonia

Maroun M. Tawk, M.D. and Marwan K. Elya, M.D. — Thu, 20Â NovÂ 2008 00:00:00 -05:00

An 84-year-old man with coronary artery disease, atrial fibrillation, chronic obstructive pulmonary disease, and congestive heart failure was admitted to the hospital because of a decrease in mental status. He...

EDITORIAL: Expanding the Orbit of Primary Prevention â Moving beyond JUPITER

Mark A. Hlatky, M.D. — Thu, 20Â NovÂ 2008 00:00:00 -05:00

The aphorism âprevention is better than cureâ makes perfect sense when applied to healthy habits such as following a sensible diet, maintaining an ideal body weight, exercising regularly, and not...

ORIGINAL ARTICLE: Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein

Thu, 20Â NovÂ 2008 00:00:00 -05:00

Background: Increased levels of the inflammatory biomarker high-sensitivity C-reactive protein predict cardiovascular events. Since statins lower levels of high-sensitivity C-reactive protein as well as cholesterol, we hypothesized that people with...

BOOK REVIEW:

Thu, 13Â NovÂ 2008 00:00:00 -05:00

Pulmonary hypertension and its effects on right heart function have long been an enigma to most clinicians. However, remarkable progress has been made in recent years. We are now able...

CLINICAL PROBLEM-SOLVING: Fool's Gold

Thu, 06Â NovÂ 2008 00:00:00 -05:00

A 20-year-old man presented to the emergency department after a syncopal episode. During the previous 2 weeks, he had had persistent low-grade fever, anorexia, rhinorrhea, and headache. On the morning...

CLINICAL THERAPEUTICS: Varenicline for Tobacco Dependence

J. Taylor Hays, M.D., and Jon O. Ebbert, M.D. — Thu, 06Â NovÂ 2008 00:00:00 -05:00

A 57-year-old man with a 60-pack-year history visits his primary care provider because he wants to quit smoking. He has a history of stable coronary artery disease, peripheral vascular disease,...

CORRESPONDENCE: Shifts to and from Daylight Saving Time and Incidence of Myocardial Infarction

Imre Janszky, M.D., Ph.D. and Rickard Ljung, M.D., Ph.D. — Thu, 30Â OctÂ 2008 00:00:00 -05:00

To the Editor: More than 1.5 billion men and women are exposed to the transitions involved in daylight saving time: turning clocks forward by an hour in the spring and...

EDITORIAL: Elevated C-Reactive Protein in Atherosclerosis â Chicken or Egg?

Heribert Schunkert, M.D., and Nilesh J. Samani, M.D., F.Med.Sci. — Thu, 30Â OctÂ 2008 00:00:00 -05:00

One of the most debated topics in cardiovascular medicine is whether C-reactive protein (CRP), a component of the acute-phase response, is a causal factor in the pathogenesis of atherosclerosis.12 If...

ORIGINAL ARTICLE: Genetically Elevated C-Reactive Protein and Ischemic Vascular Disease

Thu, 30Â OctÂ 2008 00:00:00 -05:00

Background: Elevated levels of C-reactive protein (CRP) are associated with increased risks of ischemic heart disease and ischemic cerebrovascular disease. We tested whether this is a causal association.

Methods: We studied...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: The Exercise Pill â Too Good to Be True?

Laurie J. Goodyear, Ph.D. — Thu, 23Â OctÂ 2008 00:00:00 -05:00

Regular physical exercise has undisputed health benefits in the prevention â and in some cases, the treatment â of many diseases. The problem is that for the great majority of...

REVIEW ARTICLE: Uric Acid and Cardiovascular Risk

Daniel I. Feig, M.D., Ph.D., Duk-Hee Kang, M.D., and Richard J. Johnson, M.D. — Thu, 23Â OctÂ 2008 00:00:00 -05:00

An association of gout with hypertension, diabetes, kidney disease, and cardiovascular disease has been observed since the late 19th century. Early investigators, such as Frederick Mahomed, Alexander Haig, and Nathan...

SPECIAL ARTICLE: Cardiovascular Outcomes after a Change in Prescription Policy for Clopidogrel

Thu, 23Â OctÂ 2008 00:00:00 -05:00

Background: Drug-reimbursement policies may have an adverse effect on patient outcomes if they interfere with timely access to efficacious medications for acute medical conditions. Clopidogrel in combination with aspirin is...

ORIGINAL ARTICLE: Pulmonary-Vein Isolation for Atrial Fibrillation in Patients with Heart Failure

Thu, 23Â OctÂ 2008 00:00:00 -05:00

Background: Pulmonary-vein isolation is increasingly being used to treat atrial fibrillation in patients with heart failure.

Methods: In this prospective, multicenter clinical trial, we randomly assigned patients with symptomatic, drug-resistant atrial...

REVIEW ARTICLE: Blunt Aortic Injury

Thu, 16Â OctÂ 2008 00:00:00 -05:00

Blunt aortic injury occurs in less than 1% of motor vehicle crashes but is responsible for 16% of the deaths.1 This injury is second only to head injury as the...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 31-2008 â A 39-Year-Old Man with Chest Pain, Arthralgias, and a Mediastinal Mass

Thu, 09Â OctÂ 2008 00:00:00 -05:00

A 39-year-old man was admitted to this hospital because of chest pain, arthralgias, and a mediastinal mass.

Two months before admission, pain in the middle and right chest developed, which radiated...

ORIGINAL ARTICLE: 10-Year Follow-up of Intensive Glucose Control in Type 2 Diabetes

Thu, 09Â OctÂ 2008 00:00:00 -05:00

Background: During the United Kingdom Prospective Diabetes Study (UKPDS), patients with type 2 diabetes mellitus who received intensive glucose therapy had a lower risk of microvascular complications than did those...

ORIGINAL ARTICLE: Long-Term Follow-up after Tight Control of Blood Pressure in Type 2 Diabetes

Thu, 09Â OctÂ 2008 00:00:00 -05:00

Background: Post-trial monitoring of patients in the United Kingdom Prospective Diabetes Study (UKPDS) examined whether risk reductions for microvascular and macrovascular disease, achieved with the use of improved blood-pressure control...

IMAGES IN CLINICAL MEDICINE: Pneumopericardium

Mehdi Karoui, M.D., Ph.D. and Petru Octav Bucur, M.D. — Thu, 02Â OctÂ 2008 00:00:00 -05:00

A 47-year-old homeless man presented to the emergency department 1 week after the onset of chest pain. He was hemodynamically stable. The physical examination was unremarkable. A routine complete blood...

PERSPECTIVE: The Statins in Preventive Cardiology

Thu, 02Â OctÂ 2008 00:00:00 -05:00

The discovery of the statins by Akira Endo and colleagues in 1976 opened the door to a new era in preventive cardiology.1 The importance of this discovery was recently underscored...

EDITORIAL: Ezetimibe and Cancer â An Uncertain Association