The management of congestive heart failure.

Despite the remarkable advances in cardiovascular therapeutics over the past four decades, little impact has been made on either the incidence or mortality rate of congestive heart failure and it remains a major clinical and public health problem. Recent practice audits have suggested that proven efficacious therapies are not maximally applied in patients with this condition. An approach to the patient with congestive heart failure is presented, emphasizing the two distinct syndromes of systolic dysfunction and diastolic dysfunction. Treatment recommendations are derived from consideration of the underlying pathophysiology and the evidence from randomised clinical trials.     

慢性心力衰竭中医研究进展

慢性心力衰竭是一种进展性的临床综合征,已经成为全球公共健康的主要难题之一。上世纪90年代以来,西医在慢性心衰的治疗上取得了重大突破;近年来中医药在治疗慢性心衰及合并症上也取得了可喜的成果。文章主要就近年来中医对心衰的研究进行综述。     

高血压肥胖发病机制研究进展

原发性高血压是全球范围内的重大公共问题 ,能导致全身各主要脏器的严重损害 ,引起脑血管意外、冠心病、心力衰竭、肾功能不全等并发症。体重超重和肥胖作为原发性高血压病最重要的危险因素之一 ,日益引起人类的关注。本文对高血压肥胖的发病进行了综述 ,给医务工作者提供近年来关于高血压肥胖的国内外研究概况 ,以便更好地预防和治疗高血压肥胖     

Cachexia in malaria and heart failure: therapeutic considerations in clinical practice

Cachexia is an independent prognostic marker of survival in many chronic diseases including heart failure and malaria. Morbidity and mortality from malaria is high in most of the third world where it presents a very challenging public health problem. Malaria may present in the UK as fever in the returning traveller or as fever in overseas visitors. How and why cachexia develops in malaria in a manner similar to the cachexia of chronic heart failure and the treatment strategies that would alter outcomes in both diseases are discussed in this review.     

ACEI——慢性充血性心力衰竭治疗的基石

慢性充血性左心力衰竭已成为全球严重的公共卫生问题，不但是心脏病患者预后不良的重要预测因素，而且消耗了大量卫生资源。80年代以来，多中心大规模随机临床试验的结果证明，血管紧张素转换酶抑制剂(ACEI)可以改善充血性左心力衰竭患者的预后，并已成为慢性充血性心力衰竭治疗的基石。     

健康教育对冠脉介入诊疗并发症影响的Meta分析

目的 对国内健康教育干预对冠心病介入诊疗并发症的影响进行评价.方法 数据库检索国内相关文献,据一定纳入和排除标准筛选文献,并按Cochrane系统评价手册5.0的文献质量评价办法对纳入研究进行方法学质量评价,而后提取有效数据并采用RevMan5.1软件进行Meta分析.结果 共纳入7个随机对照试验,方法学质量均为B级.Meta分析结果显示,健康教育干预组与常规护理组在术后并发症尿潴留、局部红肿、拔管综合征、伤口出血的发生率方面差异具有统计学意义,其RR(95％CI)分别为0.17(0.10,0.29)、0.13(0.04,0.42)、0.09(0.02,0.31)、0.35 (0.21,0.59).结论 健康教育干预可减少冠脉介入诊疗术后并发症如尿潴留、局部红肿、拔管综合征、伤口出血的发生率.     

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.     

Losing the battle of the bulge: causes and consequences of increasing obesity.

Increasing proportions of Australians are overweight or obese, a problem shared by all developed and, increasingly, developing nations. Now as many people in the world are overweight as underweight. Increasing obesity is a serious public health as well as economic problem. Its associated greater risks of high blood pressure, heart disease, osteoarthritis, type 2 diabetes, some cancers and other health problems consume considerable proportions of healthcare budgets. Health inequalities often reflect social inequalities, but with overweight there is also a male-female difference in the relationship between overweight and socioeconomic status. Health promotion campaigns are underestimating the social determinants of health, and "risk fatigue" is affecting attitudes to complying with healthy lifestyle standards. Proposals to reverse the obesity trend, such as taxing or restricting the advertising of unhealthy foods, raise contentious issues of choice and regulation.     

Sudden cardiac death and the potential role of beta-adrenoceptor-blocking drugs.

Sudden cardiac death is a major health problem in the industrially developed countries. The risk of sudden cardiac death may be reduced by early detection of coronary heart disease, elimination of the risk factors, treatment of the ischaemia in patients known to have coronary heart disease and suppression of ventricular arrhythmias. Of all the therapeutic measures currently available to reduce the risk of sudden cardiac death, beta-adrenoceptor-blocking drugs (beta blockers) appear to be the most effective. In this paper their actions are reviewed and evidence for their efficacy is presented.     

ADDRESSES AND REVIEWS THE PROBLEM OF THE STREPTOMYCIN-RESISTANT TUBFRCLE BACILLI ltN THF TREATMENT OF TUBFJRCULOSIS

After extensive trials of the antibiotic, streptomycin, in the treatment of various forms of tuberculosis inihuman patients, most clinicians have come to consider this-new antibiotic as the best available. However, the therapeutic potentialitie.s of this agent are greatly limited and its us''e is-sometimes discarded, because of the relatively short duration of its antibacterial action, and the ease in the development of resistance. The latter is considered undesirable because in the first place, organisms re8istant to streptomycin in vitro have been proven to be also resistant to the action of streptomycin in vivo, and when still virulont, will render further treatment ineffective (1). It must be mentioned that by the term resistance, there may be only as little as ,O.1U/o of the organisms in the culture which is actually not susceptible to the anti- ''oacterial action of a certain dose of streptomycin, usually.placed at 10 gm. per ml. (2). In the second place, the dissemination of resistant organism is a public hazard because there will be lack of response of 11atients infected with these resistant organisms to streptomycin.     

DIAGNOSIS AND TREATMENT OF SICK SINUS SYNDROME

At a panel discussion, medical workers from some 20 hospitals in Beijing exchanged e'x- periences and views on the clinical aspects of sick sinus syndrome. In a combined series of 171 cases, coronary heart disease (91 cases) and cardiomyopathy or myocarditis (37 cases) were found to be the most common causes. 38 cases were of unknown etiology. The main clinical and ECG features were reviewed. Problems in diagnosis were discussed with particular em- phasis on the use of accessory diagnostic methods, such as atropine test, exercise test and ECG monitoring. Experiences in treatment with combined traditional Chinese and western me- dicine as well as with the use of artificial car- diac pacemakers were exchanged.     

冠状血管气体栓塞的治疗与实验研究

对冠状血管气体栓塞（ＣＥＡ）应用提高灌注压（桡动脉平均压１０．６６ｋＰａ以上），加大主动脉与右心房间的压力差，促使冠状血管内气体排出至右房系统在肺内被吸收的治疗方法。３例冠状血管气栓的病人经此法治疗痊愈，未留任何后遗症；经５次家兔实验进一步证实此法治疗冠状血管气体栓塞是简单可行，有效的方法。     

肺血栓栓塞症的临床诊治进展

肺血栓栓塞症(pulmonary thromboembolism,PTE)为肺栓塞最常见的类型,是指来自静脉系统或右心血栓脱落后阻塞肺动脉或其分支所导致的疾病,阻塞范围达到一定程度后致呼吸循环系统障碍引起心肺功能、血流动力学等异常,从而诱发一系列的临床表现。在曾经的临床治疗中,由于诊疗技术的落后及临床医生对肺血栓栓塞症的认识极其微薄,PTE易被误诊、漏诊,尤其易被缺乏临床经验的一线青年医师忽略,一度被认为是罕见病。近年来,大量循证医学证据表明肺血栓栓塞症在我国已成为常见病。肺血栓栓塞症具有高患病率、高复发率、高致残率、高病死率和高疾病经济负担的特点,已成为重大的健康问题,严重威胁公众人群健康的临床急症之一,有报道称肺血栓栓塞症是继冠心病、脑卒中后常见的重要死亡原因。随着诊疗技术的创新发展及临床工作者的不断探究,不论是对诱发肺血栓栓塞症危险因素的认识,或是肺血栓栓塞症临床诊断思维或治疗方案的选择,都显现出现代医务者对肺血栓栓塞症更深层的认知。但目前关于肺血栓栓塞症的诊治仍有一些问题,尤其是中危肺血栓栓塞症患者的治疗上目前未有一个统一的规范化诊治方案。本综述主要概括了肺血栓栓塞症的诊治进展。      

Passive smoking and the risk of heart disease.

OBJECTIVE--This paper reviews the evidence that exposure to environmental tobacco smoke (ETS) increases the risk of heart disease death among persons who have never smoked (never-smokers). The annual number of heart disease deaths in the United States attributable to ETS is estimated, as is the individual risk of heart disease death for exposed never-smokers. DATA SOURCES--Nine epidemiologic studies and numerous experimental studies are available to evaluate the association of ETS and heart disease. DATA SYNTHESIS--The relative risk for never-smokers living with current or former smokers, compared with never-smokers living with nonsmokers, has ranged from 0.9 to 3.0 in nine studies. Seven studies were positive, one was positive for women but not men, and one was negative. Several studies have shown a dose-response relationship and have controlled for other risk factors. Evidence from experimental studies suggests that ETS can damage the cardiovascular system, via both short-term and long-term mechanisms. Assuming that the observed heart disease risk for those exposed to ETS is not an artifact of misclassification or confounding, approximately 35,000 to 40,000 deaths from ischemic heart disease among never-smokers and long-term former smokers are estimated to have occurred annually in the United States as a result of ETS exposure in the early 1980s. An individual male never-smoker living with a current or former smoker is estimated to have an approximately 9.6% chance of dying of ischemic heart disease by the age of 74 years, compared with a 7.4% chance for a male never-smoker living with a nonsmoker. The corresponding lifetime risks for women are 6.1% and 4.9%. CONCLUSIONS--The public health burden due to ETS exposure is likely to be much greater for heart disease than for lung cancer, which has been the focus of most debate to date. Individual lifetime excess risks of heart disease death due to ETS of one to three per 100 can be compared with much lower excess risks of one death per 100,000, which are often used in determining environmental limits for other toxins. Exposure to ETS is not currently regulated at the federal level, except for domestic air traffic.     

心脏外伤的诊断及治疗(附4例报告)

本文报告4例开放性心脏损伤的救治体会。作者认为:根据心前区明显外伤史,严重失血性休克,心包填塞体征即可确立诊断。准确判断伤情,快诊、速治,及早开胸止血是抢救成功的关键。     

Coronary artery surgery.

Coronary artery disease has been described as the largest public health problem in Western society. In spite of the many advances in recent years in its medical management, many patients remain disabled even after optimal medical therapy. The aortocoronary bypass operation, introduced in the mid-1960s, has been shown to have consistent subjective and objective effects on the course of the disease in a large proportion of patients. The procedure consists of inserting a portion of the saphenous vein into both the aorta and a coronary artery to bypass the obstruction. It is usual now to bypass obstructions in several coronary arteries at the same operation if necessary. The prognosis for patients with ischemic heart disease with medical management depends on the extent of the disease. Patients with obstruction of only one coronary artery have a prognosis very little different from normal. On the other hand, obstruction of several arteries is consistently associated with a mortality approaching or exceeding 10% per year.     

Complications of hypertension as encountered by primary care physician

Hypertension is a common clinical problem with great implications for public health. It is a silent killer and often remains asymptomatic. So regular BP check-up is a must. Complications of untreated hypertension include ventricular hypertrophy, heart failure and accelerated atherosclerosis, cerebrovascular disease and stroke, renal failure and retinopathy. Primary care physicians have immense duty to perform in this regard because they are the first to encounter them in various stages of the disease. Hypertension can present per se or in emergencies (as in crisis) or in disguise of a complication (like anaemia and renal failure). Control of hypertension and delaying the development of complications should be their first goal. Lastly, some hypertensives with complications may require referral to advanced centres.     

Communication and health--health as an ecosystem

The importance of communication in public health is described with reference to recent experiences in Australia where good progress has been made with certain major public health problems. There has been a 30% fall in road accident deaths and a 40% fall in deaths from coronary heart disease, and a smoke free environment has been established in public places and in the work place. These successes depended on effective communication based on appropriate data. Evaluation data have also been used to keep the public informed and to reinforce the message. The cooperation of the media has been most important in stimulating a new awareness of health and the opportunities for self help and community initiatives. In central Australia, new initiatives involving the Central Australian Aboriginal Congress have led to an improvement in the health of Aborigines, the training of Aborigines as health workers and the development of a Centre for Appropriate Technology at the Alice Springs College of Technical and Further Education. At the international level, Australia sponsored a World Health Assembly resolution in 1986 calling for the elimination of iodine deficiency disorders. With the support of the Australian International Development Assistance Bureau and the United Nations Children's Fund (UNICEF), an international expert group of scientists and public health professionals, the International Council for Control of Iodine Deficiency Disorders (ICCIDD), based in Adelaide, has been able to work with the World Health Organization (WHO) and UNICEF in the development of an international public health programme aimed at eliminating iodine deficiency disorders by the year 2000. The ICCIDD is a new model for communication and action in international health which is now being advocated for other areas.     

Dilemmas in the management of rheumatic heart disease

Rheumatic heart disease (RHD) is a major health care problem in India and will continue to be so for few more decades. As there is no vaccine against RHD, it is difficult to control the disease. Besides RHD, most children have other preventable ailments as well. Hence the schools, specially for the poor, must act as primary and preventive health care centres. Prevention of RHD starts with school prophylaxis. Primary, secondary and tertiary prophylaxis play their roles afterwords. After the heart valves have been damaged, tertiary prevention might minimise further damage. For mitral stenosis, closed mitral valvotomy (CMV), open mitral valvotomy (OMV) and interventional mitral valvotomy (IMV) are the different options but none is curative. Valve replacement poses many problems and therefore valvotomy is deferred as far as possible. Mild or moderate mitral regurgitation (MR) is best treated medically. For more advanced disease repair or replacement is the option. For aortic stenosis (AS), valvotomy may be preferred to replacement wherever feasible and for aortic regurgitation (AR) repair is not yet well established. In combined mitral and aortic valve disease it is important to assess both the valves carefully and try to repair one or both the valves and to avoid double valve replacement as far as possible. Once the heart valve is damaged any treatment is palliative, hence all efforts should be directed towards prevention of RHD. Indian Medical Association can play a major role in this endeavour and help children in India to grow up free from RHD.