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Review Article
Current Concepts: Cognitive and Neurologic Outcomes after Coronary-Artery Bypass Surgery
Patients referred for coronary revascularization procedures are older and are likely to have more extensive extracardiac vascular disease than those referred for such procedures in the past. Despite these trends, mortality rates for coronary-artery bypass grafting (CABG), without concurrent…
- January 19, 2012
- Selnes O.A., Gottesman R.F., Grega M.A., et al.
- N Engl J Med 2012; 366:250 - 257
- CME
For patients undergoing coronary-artery bypass grafting (CABG), adverse neurologic outcomes, including stroke and cognitive decline, are major concerns. Even mild cognitive deficits before surgery may be a marker for cerebrovascular disease and increased risk.
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Correspondence
Acute Coronary Thrombosis in Boston Marathon Runners
To the Editor: Regular exercise reduces the incidence of coronary atherosclerotic disease and decreases mortality after myocardial infarction, but vigorous activity increases the risk of myocardial infarction and sudden death among patients with occult and diagnosed coronary artery disease. We…
- January 12, 2012
- N Engl J Med 2012; 366:184 - 185
- Free Full Text
Three well-conditioned men who ran the 2011 Boston Marathon had acute coronary thrombosis shortly after completing the marathon. The authors discuss possible explanations for the occurrence of coronary thrombosis after prolonged exertion.
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Images in Clinical Medicine
Jugular Venous C-V Wave in Severe Tricuspid Regurgitation
Figure 1.
- January 12, 2012
- Senguttuvan N.B. and Karthikeyan G.
- N Engl J Med 2012; 366:e5
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- Video
An 18-year-old man presented with a history of progressive anasarca and exertional dyspnea. His jugular venous pressure was elevated and showed prominent systolic pulsations that were eliminated when gentle pressure was applied at the base of the neck.
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Review Article
200th Anniversary Article: A Tale of Coronary Artery Disease and Myocardial Infarction
The remarkable facts, that the paroxysm, or indeed the disease itself, is excited more especially upon walking up hill, and after a meal; that thus excited, it is accompanied with a sensation, which threatens instant death if the motion is persisted in; and, that on stopping, the distress…
- January 5, 2012
- Nabel E.G. and Braunwald E.
- N Engl J Med 2012; 366:54 - 63
- Free Full Text
In this review of heart disease, Nabel and Braunwald focus on two themes — coronary artery disease and myocardial infarction — and explain how our understanding has evolved over the past two centuries. The authors consider therapies that have led to improved survival.
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Clinical Therapeutics
Catheter Ablation for Atrial Fibrillation
Foreword. This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this therapy, and potential adverse effects are…
- December 15, 2011
- Wazni O., Wilkoff B., Saliba W.
- N Engl J Med 2011; 365:2296 - 2304
- CME
A 59-year-old man presents with a recurrent episode of symptomatic atrial fibrillation despite attempts to maintain sinus rhythm with antiarrhythmic drugs. Catheter ablation can be effective in such patients, but more than one procedure may be necessary.
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Images in Clinical Medicine
Thrombosis of a Mechanical Mitral Valve
Figure 1.
- December 15, 2011
- Harris K.C. and Campbell A.I.M.
- N Engl J Med 2011; 365:e45
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- Video
An 8-year-old girl with a history of congenital mitral stenosis and mitral-valve replacement presented with dyspnea on exertion, fatigue, and orthopnea. On examination, she had tachypnea, a heart rate of 130 bpm, and oxygen saturation of 85 to 87% while breathing ambient air.
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Images in Clinical Medicine
Internal-Carotid-Artery Dissection and Cranial-Nerve Palsies
Figure 1.
- December 8, 2011
- Peltz E. and Köhrmann M.
- N Engl J Med 2011; 365:e43
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- Video
A 45-year-old woman presented to the emergency department 3 days after the acute onset of severe dysphagia, breathy dysphonia, and earache and pulsatile tinnitus in the left ear. Her medical history was unremarkable. Physical examination revealed leftward ...
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Original Article
Abciximab and Heparin versus Bivalirudin for Non–ST-Elevation Myocardial Infarction
An invasive strategy of coronary angiography, with revascularization when appropriate, is recommended for high-risk patients who have an acute coronary syndrome. Owing to the key role that the rupture of an atherosclerotic plaque, which is highly prothrombotic, plays in the pathogenesis of these…
- November 24, 2011
- Kastrati A., Neumann F.-J., Schulz S., et al.
- N Engl J Med 2011; 365:1980 - 1989
- CME
This trial compared the combination of abciximab and unfractionated heparin with bivalirudin in patients with non–ST-segment elevation MI who were undergoing coronary stenting. The two regimens had similar efficacy, but there was more bleeding with abciximab and heparin.
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Images in Clinical Medicine
Ortner's Syndrome
Figure 1.
- September 8, 2011
- Prada-Delgado O. and Barge-Caballero E.
- N Engl J Med 2011; 365:939
- Free Full Text
A 62-year-old woman presented with a 2-year history of progressive vocal hoarseness. She had had mitral-valve replacement for rheumatic mitral stenosis 21 years earlier, but her severe pulmonary hypertension had not resolved, and progressive clinical manifestations had developed.
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Images in Clinical Medicine
Lung Herniation after Minimally Invasive Cardiothoracic Surgery
Figure 1.
- September 1, 2011
- Weymann A. and Szabo G.
- N Engl J Med 2011; 365:e19
- Free Full Text
One year after undergoing minimally invasive direct coronary-artery bypass surgery, a 67-year-old man was admitted to hospital with a well-demarcated deformity overlying the third intercostal space of the left anterior hemithorax. On examination, the ...
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Clinical Problem-Solving
Looking at the Whole Picture
Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows. Stage. A 50-year-old woman presented with…
- August 4, 2011
- Donagh C., Bruzzi J., MacNeill B., et al.
- N Engl J Med 2011; 365:448 - 453
- CME
- Video
A 50-year-old woman presented with rapidly progressive shortness of breath. Five months earlier, she had received a diagnosis of invasive breast carcinoma and had undergone mastectomy. Her fifth cycle of chemotherapy was completed 10 days before presentation.
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Original Article
Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients
After the appearance of symptoms, aortic stenosis is associated with a high rate of death if left untreated.– Although surgical aortic-valve replacement improves symptoms and survival,– observational studies have identified various subgroups of patients (i.e. those with an advanced age and…
- June 9, 2011
- Smith C.R., Leon M.B., Mack M.J., et al.
- N Engl J Med 2011; 364:2187 - 2198
- Free Full Text
- Video
This study examines use of an expandable bovine pericardial prosthetic valve inserted with a catheter system for valvular aortic stenosis. Outcomes were noninferior to those of surgical aortic-valve replacement, but the risk of stroke, aortic regurgitation, and vascular complications was substantial.
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Editorial
Transcatheter Aortic-Valve Implantation — At What Price?
In 2000, Bonhoeffer et al. described transvenous placement of a pulmonary-valve prosthesis and speculated that similar technology might be used in other cardiac valves, including the aortic position. Two years later, the first transcatheter insertion of an aortic-valve prosthesis was performed by…
- June 9, 2011
- Schaff H.V.
- N Engl J Med 2011; 364:2256 - 2258
In 2000, Bonhoeffer et al. described transvenous placement of a pulmonary-valve prosthesis and speculated that similar technology might be used in other cardiac valves, including the aortic position.¹ Two years later, the first transcatheter insertion of ...
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Original Article
Randomized Trial of Stents versus Bypass Surgery for Left Main Coronary Artery Disease
A number of registry reports, as well as a substudy from a large, randomized trial, have indicated that percutaneous coronary intervention (PCI) may be an acceptable alternative to coronary-artery bypass grafting (CABG) in some patients with unprotected left main coronary artery stenosis.– Recent…
- May 5, 2011
- Park S.-J., Kim Y.-H., Park D.-W., et al.
- N Engl J Med 2011; 364:1718 - 1727
- Free Full Text
Patients with unprotected left main coronary artery stenosis were assigned to either CABG or PCI with sirolimus-eluting stents. At 1 year, with a wide prespecified noninferiority margin, PCI was found to be noninferior to CABG.
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Original Article
Myocardial Viability and Survival in Ischemic Left Ventricular Dysfunction
Coronary artery disease is an important contributor to the rise in the prevalence of heart failure and in associated mortality and morbidity.– It has not been clearly established whether coronary-artery bypass grafting (CABG) has a role in improving the symptoms and the rate of survival of…
- April 28, 2011
- Bonow R.O., Maurer G., Lee K.L., et al.
- N Engl J Med 2011; 364:1617 - 1625
- Free Full Text
- CME
Patients with CAD and LV dysfunction were assigned to receive either medical therapy alone or medical therapy plus CABG. There was no evidence of significant interaction between myocardial viability and treatment assignment.
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Original Article
Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction
It is estimated that 5.8 million patients in the United States and 15 million in Europe have heart failure. Coronary artery disease is the most common substrate for heart failure in industrialized nations. However, the role of coronary-artery bypass grafting (CABG) in the treatment of patients with…
- April 28, 2011
- Velazquez E.J., Lee K.L., Deja M.A., et al.
- N Engl J Med 2011; 364:1607 - 1616
- Free Full Text
- CME
Patients with CAD and LV dysfunction were assigned to either medical therapy alone or medical therapy plus CABG. At 5 years, there was no significant difference between the two study groups in the rate of death from any cause.
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Editorial
Underestimating Medical Therapy for Coronary Disease . . . Again
The question of how best to treat patients with multivessel coronary artery disease and left ventricular dysfunction has challenged physicians for years. Although most clinicians are comfortable recommending revascularization when there is angina, extensive coronary disease, and a left ventricular…
- April 28, 2011
- Fang J.C.
- N Engl J Med 2011; 364:1671 - 1673
The question of how best to treat patients with multivessel coronary artery disease and left ventricular dysfunction has challenged physicians for years. Although most clinicians are comfortable recommending revascularization when there is angina, ...
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Original Article
Percutaneous Repair or Surgery for Mitral Regurgitation
Severe mitral regurgitation is associated with progressive left ventricular dysfunction and congestive heart failure. Without intervention, symptomatic patients have an annual rate of death of 5% or more.– Medical management alleviates symptoms but does not alter the progression of the disease.…
- April 14, 2011
- Feldman T., Foster E., Glower D.D., et al.
- N Engl J Med 2011; 364:1395 - 1406
- Free Full Text
- Interactive/Multimedia
This study compared a percutaneous, catheter-based method, in which a clip is placed to approximate the edges of the two mitral-valve leaflets, with conventional surgery. The procedure obviated the need for open-heart surgery in 80% of the patients who received it.
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Editorial
Mitral Regurgitation — What Is Best for My Patient?
Mitral regurgitation is common, with 80% of us having some normal valve leakage detectable on echocardiography. Mild regurgitation is well tolerated and rarely leads to overt clinical disease. However, severe regurgitation overloads the left ventricle as blood is pumped both backward across the…
- April 14, 2011
- Otto C.M. and Verrier E.D.
- N Engl J Med 2011; 364:1462 - 1463
Mitral regurgitation is common, with 80% of us having some normal valve leakage detectable on echocardiography. Mild regurgitation is well tolerated and rarely leads to overt clinical disease. However, severe regurgitation overloads the left ventricle as ...
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Clinical Problem-Solving
The Right Angle
Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows. Stage. A 25-year-old man presented to a…
- April 7, 2011
- Reed M.C., Dhaliwal G., Saint S., Nallamothu B.K.
- N Engl J Med 2011; 364:1350 - 1356
- CME
- Video
A 25-year-old man presented to an ER with abdominal distention and discomfort. He had noticed his increased girth a year earlier and attributed it to beer, but it progressed after he cut back. His distention was associated with early satiety, fatigue, and exertional dyspnea.
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