Heart attacks: exploring new preventive strategies.

Ischaemic heart disease is an emerging public health problem in Sri Lanka. Implementation of programs for lifetime control and prevention of established coronary risk factors such as smoking, hyperlipidaemia, hypertension, diabetes and hereditary risk are costly and unaffordable in countries such as Sri Lanka with limited resources for health care. Other potential risk factors which are less expensive with regard to prevention require investigation. This paper summarises several studies done over the past decade at Peradeniya, to investigate three such potential coronary risk factors of IHD, namely homocysteine, vitamin C and dietary fat.     

Transient ischemic attacks and stroke.

Transient ischemic attacks (TIAs) constitute the most specific and powerful warnings of impending stroke. They are defined as brief, focal neurological events of sudden onset. Their proper recognition and treatment rank second only to the modification of risk factors in importance for stroke prevention. Carotid endarterectomy, although widely used to treat TIAs, remains unproven; randomized clinical trials are attempting to define its role. Anticoagulant therapy appears worth while for suspected cardiac embolism and possibly for disabling TIAs. Acetylsalicylic acid is the only agent that has been found to be effective in controlled trials, but questions persist about its dosage, its efficacy in women and its use after stroke. Another platelet inhibitor, ticlopidine hydrochloride, is being investigated and may prove to be an effective alternative.     

Management of transient ischaemic attacks and stroke.

The management of stroke and transient ischaemic attacks (TIAs) has changed greatly in the last two decades. The importance of good blood pressure control is the hallmark of stroke prevention. Large multicentre trials have proven beyond doubt the value of aspirin in TIAs, warfarin in patients with atrial fibrillation and embolic cerebrovascular symptoms, and carotid endarterectomy in patients with carotid TIAs. There seems little doubt that patients managed in acute stroke units are more likely to be independent at six months than those managed in a general medical ward. This article emphasizes the importance of basing clinical management on simple history taking and examination and appropriate investigation. This, combined with knowledge of the natural history risk of TIA and stroke and the results of randomised trials, allows individuals to be managed in the most appropriate manner. This review is designed to be a practical guide, useful in the day to day management of patients with cerebrovascular disease.     

Crocodile attacks in the Northern Territory of Australia.

OBJECTIVE: To examine crocodile attacks in the Northern Territory with particular reference to risk factors, range of injuries, microorganisms isolated from wounds, and surgical management; and to make recommendations for optimal treatment. DESIGN AND SETTING: The case notes of patients treated at the Royal Darwin Hospital within the last decade were reviewed retrospectively. Autopsy and newspaper reports for the same period were also reviewed. RESULTS: There were 16 reported crocodile attacks in Northern Territory waters from June 1981 to June 1991. Four of these were fatal. Most attacks resulted from swimming or wading in shallow water (13/16). Half the victims were known to be affected by alcohol. The majority of attacks occurred in failing light or at night (10/16). Injuries in survivors ranged from minor lacerations and puncture wounds to major abdominal, chest and limb trauma. Death in fatal attacks was caused by transection of the torso or decapitation. Microorganisms isolated from wound swabs included Pseudomonas, Enterococcus, Aeromonas and Clostridium species. CONCLUSIONS: Most attacks in this series could have been prevented by taking adequate precautions. The treatment of crocodile injuries must include (i) adequate wound cultures, (ii) antitetanus prophylaxis, (iii) meticulous wound debridement, (iv) appropriate broad spectrum prophylactic antibiotics and (v) allowing healing by secondary intention or delayed primary closure where appropriate.     

Panic attacks in the community. Social morbidity and health care utilization

This article focuses on social morbidity and health care utilization in persons with panic attacks not meeting full diagnostic criteria for panic disorder. The findings are based on data from a random sample of over 18,000 adults drawn from five US communities. Panic attacks not meeting full criteria for panic disorder have a relatively high lifetime prevalence (3.6% of the adult population). Persons with panic attacks had impairment in perceived physical and emotional health, and in occupational and financial functioning, increased use of health care facilities, emergency departments, and psychoactive drugs. Persons with panic attacks were intermediate in severity between those with panic disorder and those with other psychiatric disorders. The findings could not be explained by comorbidity with other psychiatric disorders. We conclude that panic attacks have clinical significance and are associated with substantial morbidity.     

Cardiac conduction abnormalities and Stokes-Adams attacks in myotonic dystrophy.

Myotonic dystrophy is a well known cause of cardiomyopathy. While various cardiac conduction abnormalities have been described in patients with myotonic dystrophy, so far only sporadic cases of Stokes-Adams attacks have been reported. Of 27 patients with this disease various conduction disturbances were detected in 17 (63%), 5 of whom presented with Stokes-Adams attacks and were found to have intracardiac conduction defects. The prognosis in four of the five patients was greatly improved with permanent pacemaker implantation.     

Heart failure in the elderly.

Heart failure commonly occurs in the elderly age group. Treatment mainly centres on the use of digoxin and diuretics. In intractable heart failure other agents ie inotropic agents and vasodilators may be considered. Routine maintenance on diuretic and digoxin should not be encouraged. A conscious effort to tail off these medication is needed.     

Transient ischaemic attacks and stroke

Stroke is the third most common cause of death and a major cause of disability in Australia. Effective prevention is the most powerful strategy for reducing the burden of stroke. Major modifiable causal risk factors for stroke include hypertension, cigarette smoking, diabetes, atrial fibrillation, and carotid stenosis. Atrial fibrillation, in particular, is under-treated in the community; almost all patients should be prescribed warfarin or aspirin, depending on their absolute risk of stroke and risk of bleeding complications. Patients with suspected acute stroke should be referred immediately to a specialist stroke unit for urgent assessment and care by an interested, organised, multidisciplinary team of stroke experts. They should undergo immediate computed tomography brain scan and, if intracranial haemorrhage is excluded, be given aspirin (160-300 mg). Rehabilitation and secondary prevention of recurrent stroke should begin on day one after stroke.     

Electrocardiographical case. Young woman with frequent syncope attacks

A 29-year-old woman with frequent syncope attacks was referred for electrophysiological study and consideration for radio-frequency ablation of her ventricular arrhythmias. Her ECG showed features of right ventricular outflow tract premature contraction. Differential diagnoses for the causes of syncope in this patient include: right ventricular outflow tract tachycardia, arrythmogenic right ventricular dysplasia, and neurocardiogenic syncope. She underwent a tilt table test, which showed a malignant cardioinhibitory response. She developed abrupt syncope with 32 seconds of asystole during the test. She was given intravenous atropine and was resuscitated. A dual chamber rate-responsive pacemaker was implanted for her the next day. She was discharged well subsequently. Although the prognosis in patients with prolonged aystole in malignant vasovagal syncope is unknown, most doctors will still choose to implant a permanent pacemaker for patients with malignant neurocardiogenic syncope when the sinus arrest is prolonged.