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Sympathetic nerve sprouting midamor 45 mg low price blood pressure levels of athletes, electrical remodeling and the mechanisms of sudden cardiac death order midamor on line arrhythmia medscape. Heart failure causes cholinergic transdifferentiation of cardiac sympathetic nerves via gp130-signaling cytokines in rodents buy cheap midamor 45 mg online blood pressure medication when pregnant. Both sympathetic and parasympathetic nerves are colocated and concentrated in “ganglionated plexuses” around the pulmonary veins. On the other hand, spatially heterogeneous sympathetic denervation was similarly associated with an increased risk for atrial and ventricular arrhythmias. Mutations in genes encoding cardiac ion channel subunits also affect channel function in the central and peripheral autonomic nervous system and thereby result in 1,10 abnormal firing properties of affected neurons. Thus the cardiac sympathetic nervous system provides a potentially useful 34,35,40 target for treating patients at risk for clinical arrhythmias. D, Low-power longitudinal histologic section of the pulmonary venoatrial junction. The sleeves of atrial cardiomyocytes (asterisk) extend over the junction into pulmonary vein wall. E, Medium- power view of pulmonary vein wall 1 cm above the pulmonary venoatrial junction. Morphology and pathophysiology of target anatomical sites for ablation procedures in patients with atrial fibrillation. However, our currently available diagnostic tools do not permit unequivocal determination of the electrophysiologic mechanisms responsible for many clinical arrhythmias or their ionic bases. It is clinically difficult to separate microanatomic reentry from automaticity, and often one is left with the consideration that a particular arrhythmia is “most consistent with” or “best explained by” one or the other electrophysiologic mechanism. An episode of tachycardia caused by one mechanism can precipitate another episode caused by a different mechanism. For example, a premature complex caused by abnormal automaticity can precipitate an episode of tachycardia sustained by reentry. However, entrainment can identify arrhythmias caused by macroreentry (see later and Chapter 37). Such disorders of impulse formation can be caused by speeding or slowing of a normal pacemaker mechanism (e. A patient with persistent sinus tachycardia at rest or sinus bradycardia during exertion exhibits inappropriate sinus nodal discharge rates, but the ionic mechanisms responsible for sinus nodal discharge can still be normal, although the kinetics or magnitude of the currents can be altered. In vitro studies have demonstrated that myofibroblasts in infarct scars depolarize cardiomyocytes by heterocellular electrotonic interactions via 1 gap junctions and also induce synchronized spontaneous activity in neighboring cardiomyocytes. Abnormal Automaticity The mechanisms responsible for normal automaticity are described earlier (Phase 4: Diastolic Depolarization). When thef membrane potential is between −50 and −70 mV, the cell may be quiescent. Electrotonic effects from surrounding normally polarized or more depolarized myocardium influence the development of automaticity. Abnormal automaticity can be produced in normal muscle or Purkinje fibers by appropriate interventions, such as passage of current that reduces the diastolic membrane potential. An automatic discharge rate speeds up with progressive depolarization, and hyperpolarizing pulses slow the spontaneous firing. It is possible that partial depolarization and failure to reach normal maximal diastolic potential can induce automatic discharges in most if not all cardiac fibers. Although this type of spontaneous automatic activity has been found in human atrial and ventricular fibers, its relationship to the genesis of clinical arrhythmias has not been established. Indeed, Purkinje myocytes isolated from mice heterozygous for an arrhythmia-causing mutation in the gene 2+ encoding the cardiac ryanodine receptor Ca -release channel (RyR2) display a greater propensity for the 2+ development of arrhythmogenic Ca -handling abnormalities than do nonmutant ventricular cardiomyocytes. This proarrhythmic behavior is further exacerbated by catecholaminergic stimulation with the development of triggered beats (eFig. Note that the action potential upstroke is preceded by a low- 2+ amplitude elevation in Ca , followed by a suprathreshold membrane depolarization that triggers a markedly prolonged action potential. Purkinje cells from RyR2 mutant mice are highly arrhythmogenic but responsive to targeted therapy. Triggered Activity Automaticity is the property of a fiber to initiate an impulse spontaneously, without need for prior stimulation, so that electrical quiescence does not occur. Triggered activity is initiated by afterdepolarizations, which are depolarizing oscillations in membrane voltage induced by one or more preceding action potentials. Thus, triggered activity is pacemaker activity that results as a consequence of a preceding impulse or series of impulses, without which electrical quiescence occurs (Fig. This triggering activity is not caused by an automatic self-generating mechanism, and the term “triggered automaticity” is therefore contradictory. Not all afterdepolarizations may reach the threshold potential, but if they do, they can trigger another afterdepolarization and thus self-perpetuate. Polymorphic ventricular tachycardia (torsades de pointes) occurred within about 17 minutes of epinephrine administration, followed by marked bradycardia and death 2 minutes after the arrhythmia. Suppression of early and late afterdepolarizations by heterozygous knockout of the Na /Ca+ 2+ exchanger in a murine model. Middle panel, Representative series of images showing changes in [Ca ] during ai 2+ 2+ Ca wave in a single cardiomyocyte loaded with a Ca -sensitive fluorescent dye. When fibers in the rabbit, canine, simian, and human mitral valves and in the canine tricuspid valve and coronary sinus are superfused with 1 norepinephrine, they exhibit the capability for sustained, triggered rhythmic activity. In vivo, atrial and ventricular arrhythmias apparently caused by triggered activity have been reported in the dog and possibly in humans. RyR2 interacts with a number of 2+ accessory proteins to form a macromolecular Ca -release complex (eFig. The Ca -conducting pore is believed to be created at the central axis of the tetrameric structure. Premature stimulation exerts a similar effect: the shorter the premature interval, the larger the amplitude and the shorter the escape interval of the triggered event. Further, because a single premature stimulus can both initiate and terminate triggered activity, differentiation from reentry (see later) becomes difficult. The response to overdrive pacing may help separate triggered arrhythmias from reentrant arrhythmias. However, the usefulness of this approach is limited because of the profound differences in electrophysiologic properties between the murine and human heart. Collectively, pluripotent stem cell technology now offers a unique platform to evaluate patient-specific arrhythmia mechanisms and to evaluate and optimize patient therapy. Marked transmural dispersion of repolarization can create a vulnerable window for the development of reentry. Direct experimental evidence of the existence of transmural dispersion in the action potential has been provided for the human heart.

Ganapathy S: Wound/intra-articular infiltration or peripheral nerve blocks for orthopedic joint surgery: efficacy and safety issues discount midamor on line arrhythmia recognition poster. Hebl J: Clinical pathways for total joint arthroplasty: essential components for success safe 45 mg midamor blood pressure medication makes me feel weird. Kuper M discount midamor 45 mg overnight delivery arteria vesicalis medialis, Rosenstein A: Infection control in total knee and total hip arthroplasties. Suggested Viewing Links are available online to the following videos: Total Knee Replacement Surgery by Dr. A proximal tibial osteotomy involves correcting malalignment (valgus and varus) of the lower extremity by excising a wedge of bone from the tibia and correcting the mechanical axis. The affected leg generally is placed in traction, on a fracture table, via stirrup or calcaneal pin. Following the incision, an awl is used to make an entry hole in the proximal metaphysis of the tibia, through which a guide wire is introduced. The guide wire is placed across the aligned fracture, and the nail is introduced and driven over the guide wire. Before nail insertion, the medullary canal often is reamed to allow use of a larger nail. Most nails are interlocked both proximally and distally with screws that pass from the bone through holes in the nail. Stainless steel pins are drilled into the proximal and distal fragments of the fracture through stab wounds in the skin and subcutaneous tissues. Pin clamps and an external frame are attached and the fracture aligned with the assistance of the I. Following fracture alignment, the pin clamps and frames are tightened to hold fracture alignment. Wound irrigation and debridement often accompany application of the fixation frame. A longitudinal incision is made over the fractured medial and/or lateral malleoli. Dissection is carried directly down to the bone, and the fracture is identified and reduced under direct vision. The fractures are realigned under direct vision and fixed and stabilized with pins, plates, and/or screws. The fracture is mobilized, usually grafted with autogenous or allograft bone, and realigned. With an anterior approach, a longitudinal incision is made anteromedial or anterolateral to the shaft of the tibia. If the tibia is approached with a posterolateral incision, the patient is turned prone and a longitudinal incision is made just posterior to the fibula. Dissection is carried down posteriorly to the interosseous membrane, to the tibia, and the procedure becomes identical to the anterior approach. In the case of a malunion, the bone may be osteotomized with a saw or osteotomes to allow realignment. If skeletal fixation is used, a plate may be attached to the bone through the same incision. Alternatively, an intramedullary nail may be placed through an incision anterior to the tibial tubercle. If an intramedullary device is used, the canal may be reamed with intramedullary reamers prior to placement of the nail. A third type of skeletal fixation is the external fixator that stabilizes the nonunion via percutaneous pins placed into the proximal and distal tibia, which are then spanned by a device with pin clamps at both ends. An intraop x-ray is often used to confirm fixation and placement of devices; alternatively, an I. Variant procedure or approaches: Autogenous bone grafting from the iliac crest is commonly used to stimulate healing. An incision is made directly over the iliac crest, and muscles are stripped from the crest and table of the ilium. Osteotomes and gouges are used to remove either the inner or outer table of the ilium and cancellous bone between the two tables. The ankle joint generally is inspected through anterolateral and anteromedial portals (entry wounds). If the ankle joint is tight, a mechanical distractor (external fixator distraction apparatus spanning the ankle joint) may be used. The distractor is attached to the bones via percutaneous pins, as in the case of the application of an external fixator. The joint usually is opened with an anterolateral midline or anteromedial longitudinal incision. Tendons and neurovascular structures are carefully retracted to expose the joint capsule, which is then opened in line with the skin incision. After intraarticular pathology is addressed, careful closure of the capsule is performed, taking care to obtain good hemostasis. The ankle joint is exposed, and the surfaces of the joint are debrided either with osteotomes or a burr. Cancellous bone is exposed on the distal tibia and talus, and the joint is clamped together either with a simple external fixation device with pins going through the distal tibia and talus, or with bone screws that go from the distal tibia into the talus. An incision is made posterior to the distal fibula, curving around the lateral malleolus and ending in the anterolateral foot. The peroneus brevis tendon is identified and detached from its musculotendinous junction in the leg, and the peroneus brevis muscle is sutured to the peroneus longus tendon. A hole is drilled from anterior to posterior in the distal lateral malleolus; then the detached end of the peroneus brevis tendon is threaded through the hole. It is then attached to either the calcaneus or the talus, anterior to the lateral malleolus, with a staple or by suturing into a hole in the bone. It is more functional than below-knee amputation because patients can bear weight on the end of the stump; however, success is poor in patients with vascular disease or peripheral neuropathy. The posterior flap is dissected directly from the calcaneus, carefully preserving the tough heel pad and its blood supply. The heel pad is sutured directly to the distal tibia to prevent migration and to cover the bone end. The posterior flap is then sutured to the anterior flap with interrupted sutures and a compression dressing applied. A transverse dorsal incision is made at the transmetatarsal level, and a plantar incision is made beginning at the corners of the dorsal incision and extending distally to the metatarsal heads to create a long plantar flap. The plantar flap is reflected proximally to the midmetatarsal level and tapered distally. The metatarsals are sectioned with a saw, and nerves and tendons are sectioned proximal to the osteotomies. The plantar flap is then brought over the ends of the bones and sutured with interrupted sutures to the dorsal flap. Variant procedure or approaches: Other partial-foot amputations, such as midtarsal and ray amputation, are much less common.

In this case generic midamor 45mg line heart attack recovery, both right and left node dissections have occurred 45mg midamor with mastercard heart attack 8 months pregnant, leaving the kidney purchase midamor 45mg online blood pressure average, renal hilum, and psoas muscle exposed. Because the dissection is infrarenal and anterior to the lumbar vessels, there is residual fatty and nodal tissue at the posterior limit of the dissection. The decision to use this approach depends on cell type, age, reproductive status, and extent of disease. Generally, biopsies, a retroperitoneal lymph node dissection, omentectomy, and appendectomy also are performed. Surgery is indicated for resection of localized tumor and for staging of distant and local metastases. Additional procedures, including bowel resection or lymph node dissection, may be performed at the same time. Typically, a balanced anesthetic with inhalational agents and/or propofol infusion (25–150 mcg/kg/min) and narcotics. An epidural catheter may be placed for postop pain management and also may be used intraop to ↓ anesthetic requirements. Similar to primary cytoreduction, the surgery involves methodical and meticulous exploration of all of the abdomen and pelvis, multiple cytologies and biopsies, lysis of adhesions, and resection of the residual tumor, as well as the pelvic and periaortic lymph nodes (if not done at time of first surgery). Patients may also be candidates for secondary or tertiary cytoreductive surgical procedures, particularly if isolated recurrences are found in the setting of longer disease-free intervals. Intraabdominal assessment may be performed in conjunction with placement of an intraperitoneal port. Depending on the type of adjunctive treatment given, the patient may come to surgery in poor physical condition from malnutrition or toxicity from chemotherapy (see Table 8. Vascular access may be difficult to obtain due to sclerosis or thrombosis of peripheral veins. The surgery involves bilateral excision of lymphatic and areolar tissue in the inguinal and femoral regions, combined with removal of the entire vulva between the labia-crural folds, from the perineal body to the upper margin of mons pubis (Fig. A large surgical wound is created and, if 1° closure without tension is not possible, a skin or myocutaneous graft may be necessary. Deep pelvic nodes are almost never involved with metastases when the superficial and deep groin nodes are free of disease; therefore, a pelvic lymphadenectomy is no longer routinely performed. If presence of tumor is documented in the groin nodes, particularly in Cloquet’s sentinel nodes (the most cephalad, deep inguinal nodes), a deep pelvic lymphadenectomy may be performed. Postop radiation therapy, however, is widely used instead of a pelvic lymph node dissection to minimize operative morbidity and confer a survival advantage. En bloc radical vulvectomy incisions shown; bilateral inguinal lymphadenectomy is complete. The lateral aspect of the femoral sheath is incised along the sartorius muscle, with care being taken not to injure the femoral nerve or vessels, and the cribriform fascia is cleaned off the femoral artery. The external pudendal artery, which marks the entrance of the saphenous vein into the fossa ovalis, should be identified and ligated. The proximal and distal segments of the saphenous vein should be ligated and excised as the fibrofatty, lymph-bearing tissue of the femoral sheath is resected. Cloquet’s nodes at the femoral ring beneath the inguinal ligaments on both sides should be resected and submitted for frozen-section pathology evaluation. The deep inguinal lymphatic chain is removed on both sides by opening the inguinal canal from the external inguinal ring. The internal pudendal vessels at the posterior lateral margin of the vulvar incision are identified as they emerge from Alcock’s canal, and then they are ligated and incised. Use of electrocautery in this portion of the procedure usually tends to decrease operative blood loss. The dissection is continued along the periosteum of the symphysis at the level of the fascia of the deep muscles of the urogenital diaphragm. The bulbocavernosus, ischiocavernosus, and superficial transverse perinei muscles are removed. A circumferential vaginal incision, excluding the urethral meatus, is then performed and the vulva is removed. The incisions overlying the groin node dissections should be closed with minimal tension after placement of closed-suction Jackson-Pratt drains. The vulvar surgical wound is closed by slightly undermining the skin of the edges of the incision and suturing them to the vaginal mucosa. A vulvar reconstruction, using myocutaneous flaps, also can be performed at this time (see Pelvic Exenteration, p. Variant procedure or approaches: In 1962, Byran and associates popularized a 3- incision technique first described by Kehrer in 1918. This 3-incision technique, with separate vulva and groin incisions, is the most common approach (Fig. This operative approach has led to a significant decrease in wound infection and breakdown, apparently without increasing tumor recurrence in the inguinal dermal bridge above the symphysis pubis. The observation that almost no contralateral groin metastases occur in the absence of positive ipsilateral groin nodes allows the surgeon to perform only a unilateral groin node dissection. Recent trials have shown sentinel lymph node mapping may be an alternative to groin lymphadenectomy in select patients with early stage disease. For this approach, a radioactive tracer is injected intradermally 20–30 min before groin incision. Blue dye is also injected to improve visualization, but this is done after the patient is prepped due to the rapid movement of the dye to lymphoid tissue. Using both radioactivity and direct visualization allows identification of the sentinel lymph node. Benefits of this approach include less dissection of tissue and lower rates of postoperative complications. Radical vulvectomy is performed for invasive tumor that has not metastasized to distant sites. In: American Cancer Society Atlas of Clinical Oncology, Cancer of the Female Lower Genital Tract. It is performed in cases of biopsy-proven dysplasia with unsatisfactory colposcopy (inadequate visualization of the endocervical canal) or following endocervical curettage showing dysplasia or atypical glandular epithelial cells (Fig. Persistent abnormal cytology associated with normal colposcopy, colposcopic suspicion of invasion, and/or cervical biopsy showing microinvasive cancer is also an indication for this procedure. The surgery consists of the annular removal of a cone-shaped wedge of tissue from the cervix with a scalpel. Variant procedure or approaches: In selected patients, a laser is used in place of the scalpel. This procedure can be performed under local anesthesia with less blood loss, but operative time is usually longer. The thermal effect of the laser at the cone margins, although usually minimal, may interfere with pathologic interpretation. Approximately 1% of women with cervical carcinoma are pregnant at the time of diagnosis, and 1/1240 pregnancies is complicated by cervical cancer. Recognition and therapy of preinvasive cervical lesions during pregnancy, therefore, are of paramount importance. Because of the increased vascularity of the pregnant uterus and cervix, conization is usually associated with increased blood loss and morbidity.

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Omecamtiv mecarbil: a new cardiac myosin activator for the treatment of heart failure discount midamor 45 mg amex blood pressure chart during exercise. Hemodynamic discount midamor 45 mg line pulse blood pressure chart, echocardiographic 45mg midamor free shipping pulse pressure by age, and neurohormonal effects of istaroxime, a novel intravenous inotropic and lusitropic agent: a randomized controlled trial in patients hospitalized with heart failure. These patients are referred to as having dilated or “idiopathic” cardiomyopathy if the cause is unknown (see Chapter 77). Mutations of genes encoding cytoskeletal proteins (desmin, cardiac myosin, vinculin) and nuclear membrane proteins (lamin) have been identified thus far. However, in the presence of underlying structural heart disease, these conditions often lead to overt congestive heart failure. Moreover, recent reports from Scotland, Sweden, and the United Kingdom also suggested that survival 3 rates may be also improving following hospital discharge. Controversy has also arisen regarding the impact of race on outcome, with higher mortality rates being reported in blacks in some but not all studies. Additional socioeconomic factors may influence outcomes in black patients, such as geographic location and access 6 to health care. Most of the factors listed as outcome predictors have withstood univariate analysis at least, with many standing out independently when multifactorial analysis techniques are employed. Nonetheless, it is extraordinarily difficult to determine which prognostic variable is most important to predict individual patient outcome in either clinical trials or, more importantly, during the day-to-day management of an individual patient. This model provides an accurate estimate of 1-, 2-, and 3-year survival with the use of easily obtained clinical, pharmacologic, device, and laboratory characteristics and is accessible free of charge to all health care providers as an interactive Internet-based program (http://depts. Cardiac troponin T and I, sensitive markers of myocyte damage, may be elevated in patients with nonischemic and predict adverse cardiac outcomes. However, it is unclear whether anemia is a cause of decreased survival or simply a marker of more advanced disease. The underlying cause for anemia is likely multifactorial, including reduced sensitivity to erythropoietin receptors, presence of a hematopoiesis inhibitor, and defective iron supply for erythropoiesis. The lack of effect of darbepoetin alfa was consistent across all prespecified subgroups. Importantly, treatment with darbepoetin alfa led to an early (within 1 month) and sustained increase in Hb level throughout the study. A, Kaplan-Meier estimate of the probability of the death or heart failure hospitalization (primary endpoint). Treatment of anemia with darbepoetin alfa in systolic heart failure N Engl J Med 2013;368:1210. These patients represented a high-risk group with an approximately 50% increased relative mortality risk 11 compared with patients who had normal renal function. Renal function, neurohormonal activation, and survival in patients with chronic heart failure. Prevalence and prognostic significance of heart failure stages: application of the American College of Cardiology/American Heart Association heart failure staging criteria in the community. Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Minor criteria are acceptable only if they cannot be attributed to another medical condition (e. This most frequently occurs after cardiac surgery, in the setting of severe brain injury, or after a systemic infection. Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. As discussed subsequently, these goals generally require a strategy that combines diuretics (to control salt and water retention) with neurohormonal interventions (to minimize cardiac remodeling). General Measures Identification and correction of the condition(s) responsible for the cardiac structural and functional abnormalities are critical (see Table 25. Further, clinicians should aggressively screen for and treat comorbidities such as hypertension and diabetes that are believed to underlie the structural heart disease. Patients suspected of having an alcohol-induced cardiomyopathy should be advised to abstain from alcohol consumption indefinitely. Patients should be advised to weigh themselves regularly to monitor weight gain and to alert a health care provider or adjust their diuretic dose in the event of a sudden unexpected weight gain of more than 3 to 4 pounds over a 3 day period. For euvolemic patients, regular isotonic exercise such as walking or riding a stationary-bicycle ergometer may be useful as an adjunctive therapy to improve clinical status after patients have undergone exercise testing to determine suitability for exercise training (patient does not develop significant ischemia or arrhythmias). Fluid restriction (<2 L/day) should be considered in hyponatremic patients (<130 mEq/L), or for those patients whose fluid retention is difficult to control despite high doses of diuretics and sodium restriction. The measurement of nitrogen balance, caloric intake, and prealbumin may be useful in determining appropriate nutritional supplementation. However, treatment with diuretics can also lead to deterioration of renal function and worsening neurohormonal activation. The loop diuretics increase sodium excretion by up to 20% to 25% of the filtered load of sodium, enhance free water clearance, and maintain their efficacy unless renal function is severely impaired. In contrast, the thiazide diuretics increase the fractional excretion of sodium to only 5% to 10% of the filtered load, tend to decrease free water clearance, and lose their effectiveness in patients with impaired renal function (creatinine clearance <40 mL/min). Drugs that cause solute diuresis are subdivided into two types: osmotic diuretics, which are nonresorbable solutes that osmotically retain water and other solutes in the tubular lumen, and drugs that selectively inhibit ion transport pathways across tubular epithelia, which constitute the majority of potent, clinically useful diuretics. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Because furosemide, bumetanide, and torsemide are bound extensively to plasma proteins, delivery of these drugs to the tubule by filtration is limited. However, these drugs are secreted efficiently by the organic acid transport system in the proximal + + − tubule and thereby gain access to their binding sites on the Na -K -2Cl symporter in the luminal membrane of the ascending limb. Thus the efficacy of loop diuretics depends on sufficient renal plasma blood flow and proximal tubular secretion to deliver these agents to their site of action. Probenecid shifts the plasma concentration-response curve for furosemide to the right by competitively inhibiting furosemide excretion by the organic acid transport system. Agents in a second functional class of loop diuretics, typified by ethacrynic acid, exhibit a slower onset of action and have delayed and only partial reversibility. Loop diuretics are believed to improve symptoms of congestion by several mechanisms. First, loop + + − diuretics reversibly bind to and reversibly inhibit the action of the Na -K -2Cl cotransporter, thereby preventing salt transport in the thick ascending loop of Henle. Inhibition of this symporter also inhibits 2+ 2+ Ca and Mg resorption by abolishing the transepithelial potential difference that is the driving force for absorption of these cations. The decreased resorption of water by the collecting duct results in the + production of urine that is almost isotonic with plasma. The increase in delivery of Na and water to the + distal nephron segments also greatly enhances K excretion, particularly in the presence of elevated aldosterone levels.

Sex differences in hospital mortality after coronary artery bypass surgery: evidence for a higher mortality in younger women order cheapest midamor and midamor nhanes prehypertension. Off-pump coronary bypass provides reduced mortality and morbidity and equivalent 10-year survival order midamor online heart attack telugu movie review. Sex differences in mortality after transcatheter aortic valve replacement for severe aortic stenosis buy online midamor blood pressure chart pregnant. Sex-Specific Differences at Presentation and Outcomes Among Patients Undergoing Transcatheter Aortic Valve Replacement: A Cohort Study. Transcatheter Mitral Valve Repair in Surgical High- Risk Patients: Gender-Specific Acute and Long-Term Outcomes. A call to action: women and peripheral artery disease: a scientific statement from the American Heart Association. Sex Differences in the Incidence of Peripheral Artery Disease in the Chronic Renal Insufficiency Cohort. One-year costs in patients with a history of or at risk for atherothrombosis in the United States. A population-based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences. Sex differences in calf muscle hemoglobin oxygen saturation in patients with intermittent claudication. Gender differences in interventional management of peripheral vascular disease: evidence from a blood flow laboratory population. An evaluation of gender and racial disparity in the decision to treat surgically arterial disease. Analysis of gender-related differences in lower extremity peripheral arterial disease. Outcome after leg bypass surgery for critical limb ischemia is poor in patients with diabetes: a population-based cohort study. Risk Factors for Incident Hospitalized Heart Failure With Preserved Versus Reduced Ejection Fraction in a Multiracial Cohort of Postmenopausal Women. Outcome of heart failure with preserved ejection fraction in a population-based study. Differences in preeclampsia rates between African American and Caucasian women: trends from the National Hospital Discharge Survey. Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy. Gender-specific risk stratification with B-type natriuretic peptide levels in patients with acute dyspnea: insights from the B-type natriuretic peptide for acute shortness of breath evaluation study. Sex differences in clinical characteristics and long- term outcome in acute decompensated heart failure patients with preserved and reduced ejection fraction. Trends in use of implantable cardioverter- defibrillator therapy among patients hospitalized for heart failure: have the previously observed sex and racial disparities changed over time? Sex differences in implantable cardioverter- defibrillator outcomes: findings from a prospective defibrillator database. Cardiac resynchronization therapy in women versus men: observational comparative effectiveness study from the National Cardiovascular Data Registry. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American association of Cardiovascular and Pulmonary Rehabilitation. Heart failure as a newly approved diagnosis for cardiac rehabilitation: challenges and opportunities. In the current era, the number of pregnancies in women with cardiovascular disease is increasing, in part due to the growing population of women with congenital heart disease, the older age at conception, and the larger number of pregnant women with comorbidities such as obesity, hypertension, and diabetes. Thus, there is an increasing need for the cardiologist to understand pregnancy and its impact on women with heart disease. Even in otherwise healthy women, pregnancy outcomes are important for the cardiologist to consider. Maternal complications that develop during pregnancy can be predictors of long-term cardiovascular health. For instance, women with placental disorders, hypertensive disorders of pregnancy, or pregnancy- 1,2 related diabetes mellitus have high rates of cardiovascular disease later in life. When encountered in clinical practice, therefore, pregnancy complications may provide an opportunity for early identification 3 of women at increased risk for development of cardiovascular disease later in life, and perhaps such women should be referred to their primary care physician or a cardiologist to monitor cardiovascular risk factors. Most women with cardiovascular disease are aware of their cardiac condition prior to pregnancy. Less commonly, cardiovascular disease may come to attention for the first time during pregnancy either because it was previously unrecognized or because it developed de novo. Although women with cardiac disease should have preconception counseling, many have not been adequately informed about the risks of pregnancy. For physicians counseling such women with cardiac disease, a comprehensive knowledge of the underlying defect as well as of the hemodynamic changes that pregnancy will impose is imperative. Fortunately, most women with cardiovascular disease can go through pregnancy successfully with proper care, but a careful prepregnancy evaluation is mandatory. For women with low-risk cardiac conditions, preconception assessment provides reassurance and may help to prevent unnecessary therapies during pregnancy. For women with moderate- and high-risk cardiac conditions, preconception counseling regarding pregnancy risks and contraception options is necessary for women to make informed, safe decisions. Detecting cardiac decompensation during pregnancy can be difficult because the symptoms and signs of a normal pregnancy can mimic those of cardiac disease. Light-headedness, shortness of breath, peripheral edema, and even syncope often occur during a normal pregnancy, leading the less experienced physician to suspect cardiac disease when none is present. An understanding of the normal findings on cardiac examination in a pregnant patient is therefore important. Women with heart disease are at increased risk 4 for maternal cardiac and perinatal complications. Most cardiac complications can be safely treated during pregnancy, but in some women, the hemodynamic stress of pregnancy leads to irreversible cardiac deterioration. Maternal deaths are now rare in Western countries, but cardiac causes of death have 5 increased and are now the most common indirect cause of maternal deaths in many countries (Fig. Although the most prevalent cardiac diagnosis among pregnant women is congenital heart disease, maternal deaths are often secondary to acquired diseases, such as myocardial infarction, aortic dissection, and cardiomyopathies. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. The plasma volume begins to increase in the sixth week of pregnancy and by the second trimester approaches 50% above baseline. This increased plasma volume is followed by a slightly lesser rise in red cell mass, which results in the relative anemia of pregnancy. The heart rate begins to increase to approximately 20% above baseline to facilitate the increase in cardiac output.