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Chapter | 31 Diseases of the Nervous System with Ocular Manifestations 529 Signs Tumours of the parietal lobe: these produce a crossed Intracranial tumours may lead to knee pain treatment yahoo discount 500 mg azulfidine fast delivery the following signs: lower homonymous quadrantanopia (from involvement of the upper fbres of the radiations) pain after lletz treatment generic azulfidine 500 mg with amex, visual and auditory Papilloedema hallucinations pain treatment center of southwest georgia purchase 500mg azulfidine with visa, and an abnormal optokinetic response to lower back pain quick treatment buy azulfidine with american express this has already been discussed in relation to intracranial the revolving drum. Precen Tumours of the occipital lobe: these produce essen tral and temporosphenoidal tumours are nearly always tially visual symptoms. Typically, there are crossed hom associated with severe papilloedema, postcentral tumours onymous quadrantic or hemianopic defects extending up with moderate papilloedema, often of short duration. Anteriorly situated tumours may cause the subcortical tumours about one-half cause papilloe a crescentic loss in the periphery of the opposite uniocular dema which is, as a rule, moderate and of short duration. Tumours of the optic thalamus and mid-brain are almost Tumours of the mid-brain: the localizing signs of invariably associated with papilloedema of great severity. All of them may mours usually accompanied by papilloedema of a grave be associated with homonymous hemianopia owing to character. The papilloedema, when it does develop, is usu modic contraction or retraction of the upper lid followed ally marked. Ventricular tumours cause a moderate papill by ptosis, together with loss of conjugate movements oedema. There are three regions of the brain, the pons, upwards, sometimes followed by a similar failure of down central white matter of the cerebral hemispheres and the ward movement. There is light-near dissociation in that the pituitary gland, in which tumours usually develop without pupillary response to light is impaired as contrasted with causing papilloedema. There may be vertical nystagmus and adduction move Paralyses of the Ocular Muscles ments on attempted vertical gaze. Except for the lateral rectus, paralyses of the other ocular At an intermediate level in the region of the cerebral muscles as a non-specifc sign of raised intracranial pres peduncles the third nerve nucleus becomes progressively sure are rare. Ipsilateral ptosis and ultimately a complete third nerve paralysis is associated with a contralateral hemiple Focal Signs gia involving a facial palsy of the upper motor neurone Apart from the general symptoms of headache and signs type (Weber syndrome, Fig. If the red nucleus is of raised intracranial pressure, intracranial tumours produce involved, tremors and jerky movements occur in the contra focal defects which are of localizing value to clinically lateral side of the body. Tumours of the frontal lobe, particularly meningio If the lemniscus is involved there may be contralateral mata of the olfactory groove, are sometimes associated hemianaesthesia. In the upper part of the pons before the the other side due to raised intracranial pressure (Foster fbres to the facial nucleus have crossed, there is again a Kennedy syndrome). Gliomas may manifest with features third nerve paralysis with contralateral hemiplegia and up of raised intracranial pressure and changes in behaviour per motor neurone type facial palsy. This sign is due to pressure on the optic radiations as may be paralysed causing loss of corneal sensation which they loop through the temporal lobe. Visual hallucinations is liable to cause neurotrophic and neuroparalytic keratitis may occur owing to irritation of the visuopsychic area. Rarely, the ffth nerve may be compressed or internuclear, is diagnostic of a lesion at this level. Chapter | 31 Diseases of the Nervous System with Ocular Manifestations 531 Frontal Motor cortex for and the resiliency of the fontanelles and gaping sutures, as motor extremities well as to the very gradual development. The eyeballs cortex Cortical usually deviate downwards, and upward movements are facial(and restricted (the setting-sun sign). This is because a dilated voluntary ventricular system compresses the vertical upgaze centre Pyramidal oculogyric) in the dorsal mid-brain. It is more often due to a dilated tract in centres posterior third ventricle, since it is also seen in cases of internal Oculomotor hydrocephalus due to aqueductal stenosis. Such children are lethargic, nerve Facial nerve subject to fts and often blind with sluggish pupils and spas Cerebral tic diplegia. Corneal anaesthesia due to involvement Closed Head Injuries of the ffth nerve may be an early occurrence. Early tinnitus and deafness on one side is associated with cerebellar Simple concussion injuries associated with blunt head symptoms, among which nystagmus is common. The sixth trauma are followed by a temporary loss of consciousness nerve is usually involved, generally with paralysis of the with subsequent full recovery, usually spontaneously. They lateral rectus only, rarely with paralysis of conjugate devia may be associated with partial or total amnesia but rarely tion. As might be expected, there is very often facial have any ophthalmic signs or symptoms. More severe inju paralysis of the peripheral type, including the orbicularis ries to the brain are frequently followed by haemorrhage palpebrarum. Hydrocephalus In congenital and early acquired hydrocephalus of infancy, optic atrophy is not infrequently found. In A group of genetic disorders inherited as autosomal domi actual clinical practice the stage of contraction may seldom nant are associated with skin manifestations and a variety of be observed. The important ones strong indication of life-threatening tentorial herniation and with relevance to ophthalmology are briefy mentioned. The fourth nerve is the most commonly affected freckles in non-exposed areas and pigmented cafe au lait among the ocular motor nerves in closed head injuries be spots of the skin, hamartomas of the iris called Lisch nodules cause it is the thinnest and has the longest intracranial and cutaneous neurofbromas which are benign tumours course. Patients are at an increased risk of developing other neoplasms of the nervous system such Fractures of the Base of the Skull as phaeochromocytomas, optic gliomas, neurofbromas, ep A subconjunctival haemorrhage arising from the fornix endymomas, meningiomas and astrocytomas. Bilateral schwannomas of the latter may also cause blood to track forwards and pro the vestibular nerve develop in over 90% of cases. A juve duce subconjunctival haemorrhage or a black eye without nile posterior subcapsular cataract is common. Fractures of the base of the skull commonly involve the Tuberous sclerosis (Bourneville disease) is caused by cranial nerves. Fractures of the base ash-leaf shaped hypopigmented macules, depigmented naevi sometimes involve the roof of the orbit but rarely traverse and shagreen patches. It may happen that the nerve is directly injured predisposed to developing ependymomas and astrocytomas. It is primary optic atrophy appear and progress to total atrophy; characterized by haemangioblastomas, which are slowly in this event blindness is absolute and permanent. These inju haemangiomas of the parenchymal organs such as the liver, ries may cause concentric contraction of the feld of vision, kidneys and pancreas. Pigmentation in and around the disc may follow choroidal angioma, glaucoma and cerebral angioma, and haemorrhage into the sheath. The pupillary reactions vary, naevus of Ota are other phakomatoses of ophthalmic interest a relative afferent pupillary defect on the side of the lesion which are described in Chapter 20, Diseases of the Retina. Chronic Progressive External Ophthalmoplegia Injuries to the Optic Nerve and Optic Chronic ophthalmoplegia of a progressive type, due to a Chiasma myopathy of the extraocular muscles, commences with See Chapter 22, Diseases of the Optics Nerve. In the course of months or years the Chapter | 31 Diseases of the Nervous System with Ocular Manifestations 533 degeneration spreads to all the ocular muscles of both Alzheimer Disease sides. Cases of isolated ophthalmoplegia of neu First described by Professor Alois Alzheimer in Germany in rogenic origin are rare, but the condition is occasionally a 1907, it is a common cause of dementia in western coun precursor or symptom of tabes or general paralysis of the tries. It may become associated later with risk factors identifed include old age, female gender and bulbar symptoms; in these cases the internal musculature a positive family history. Clinical features begin gradually in the early stages with mild memory loss, bewilderment in unfamiliar Status Dysraphicus surroundings, forgetfulness and consequent increase in this results from a defective or anomalous closure of the cognitive problems. As the disease progresses patients are neural tube and may have various ocular implications. Sleep Lysosomal Storage Disorders disturbance, delusions and hallucinations, loss of inhibi these disorders and their associated retinal lesions have tions and belligerent behaviour can occur. No defnite treatment has shown any con vincing beneft and supportive therapy is the mainstay. There is a defect in maintaining the Parkinson disease is a degenerative disease causing loss of copper balance with a defciency of caeruloplasmin and nerve cells in the pigmented substantia nigra pars compacta excessive deposition of copper in the brain, liver and various and locus coeruleus in the mid-brain, which results in a other organs. The disease usually manifests clinically after depletion of dopamine and other neurotransmitters such as the age of 6 years with hepatitis, cirrhosis, tremors, distur norepinephrine. The disorder begins in middle age, around bances of gait, dysarthria and/or psychiatric disturbances. Criteria for confrming the diagnosis include either demon Its prevalence in the general population is about 2% in those stration of Kayser?Fleischer rings or low serum caerulo over 65 years. The constellation of typical symptoms in plasmin levels of less than 20 mg/dl, as well as an increased cludes tremors, rigidity and akinesia. Suc of clinical features comprises the syndrome termed as par cessful treatment with agents to remove and detoxify the kinsonism and could be due to other conditions besides copper deposits is possible. In lead poisoning the onset is slow and the intrinsic swing, unsteadiness while turning and sometimes a festi muscles of the eye are often involved.

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Recommendation: Relative Rest for Acute Wrist Sprains Relative rest is recommended for treatment of acute wrist sprains low back pain treatment guidelines buy generic azulfidine 500 mg line. Strength of Evidence Recommended pain treatment for diverticulitis cheapest generic azulfidine uk, Insufficient Evidence (I) Level of Confidence Moderate 2 pain treatment for burns purchase azulfidine us. Recommendation: Splinting for Moderate or Severe Acute or Subacute Wrist Sprains Splinting is recommended for treatment of moderate or severe acute or subacute wrist sprains heel pain yoga treatment buy cheap azulfidine 500 mg on-line. Strength of Evidence Recommended, Insufficient Evidence (I) Level of Confidence Moderate 3. Recommendation: Self-application of Ice for Acute Wrist Sprain Self-application of ice is recommended for treatment of acute wrist sprain. Strength of Evidence Recommended, Insufficient Evidence (I) Level of Confidence Low 4. Recommendation: Self-application of Heat for Acute Wrist Sprain Self-application of heat is recommended for treatment of acute wrist sprain. Splints are recommended particularly for patients with moderate to severe sprains. Of the 2 articles considered for inclusion, zero randomized trials and 2 systematic studies met the inclusion criteria. Of the one article considered for inclusion, 1 randomized trial and zero systematic studies met the inclusion criteria. Grip study, increased wrap not Oral placebo Sciences tendinosis, strength improved pain relief, functional reported. Severe wrist sprains may require occupational or physical therapy mostly for teaching mobilization exercises. Wrist sprains that do not resolve or trends towards resolution by 6 weeks should have either further diagnostic evaluation or referral for consideration of other diagnostic testing and treatment options. Medications Over-the-counter medications are generally helpful for pain associated with wrist sprain. Frequency/Duration Scheduled dosage rather than as needed is generally preferable. Indications for Discontinuation Resolution of pain, lack of efficacy, development of adverse effects particularly gastrointestinal. They are not invasive, have few adverse effects in employed populations, and are low cost, thus they are recommended for pain associated with acute or subacute wrist sprain. Patients with deficits may require a home exercise program during recovery phases. Evidence for the Use of Exercise There are no quality studies incorporated into this analysis. Surgery Recommendation: Surgery for Treatment of Acute or Subacute Wrist Sprain Surgery is not recommended for treatment of acute or subacute wrist sprain in the absence of a remediable defect. Strength of Evidence Not Recommended, Insufficient Evidence (I) Level of Confidence High Rationale for Recommendation There are no quality studies evaluating the use of surgery for wrist sprain. Other than among patients with other trauma necessitating surgery, wrist sprains are not believed to respond to surgery. Evidence for the Use of Surgery There are no quality studies incorporated into this analysis. Mallet Finger Diagnostic Criteria Mallet finger is a clinical diagnosis with a characteristic presentation of inability to extend the distal segment when the extensor tendon is damaged. Strength of Evidence Recommended, Insufficient Evidence (I) Level of Confidence Moderate Rationale for Recommendation There are no quality studies evaluating the use of x-rays for mallet finger. X-rays may assist in identifying fractures and the magnitude of the involvement of the joint surface, which if large enough, alters management to surgery. Evidence for the Use of X-rays There are no quality studies incorporated into this analysis. Strength of Evidence Not Recommended, Insufficient Evidence (I) Level of Confidence Low Rationale for Recommendation There are no quality studies evaluating the use of ultrasound to diagnose mallet finger. While ultrasound has been used for imaging,(1040) there is no evidence it alters treatment or prognosis and x-ray studies appear sufficient for diagnostic purposes. Recommendation: Splints for Acute or Subacute Mallet Finger Extension splinting with the joint in a neutral or hyperextended position is moderately recommended for treatment of acute or subacute mallet finger. Frequency/Duration Splinting for 6 to 8 weeks, possible nocturnal use for an additional 2 to 4 weeks. Splints must hold the finger in continuous, full extension for a minimum duration of 6 weeks. Of the 12 articles considered for inclusion, 1 randomized trials and 3 systematic studies met the inclusion criteria. Recommendation: Instructions for Splint Wear It is recommended that careful instructions on splint wear be provided to patients. Strength of Evidence Recommended, Insufficient Evidence (I) Level of Confidence High Rationale for Recommendation There are no quality studies evaluating the use of instructions for splint wear for mallet finger. However, instructions appear critical for preventing treatment failures and are thus recommended. Of the 6 articles considered for inclusion, 0 randomized trials and 2 systematic studies met the inclusion criteria. Follow-up Visits Patients require a few appointments to reinforce importance of splinting and of not removing the splint unsupported. Medications Nonprescription medications are usually not required as mallet finger is generally not painful. Prescription medications are rarely required as mallet finger is generally not painful. Evidence for the Use of Medications There are no quality studies incorporated into this analysis. However, patients usually require careful education about splinting (see Education above). Evidence for the Use of Exercise There are no quality studies incorporated into this analysis. Of the 2 articles considered for inclusion, 01 randomized trials and 0 systematic studies met the inclusion criteria. Strength of Evidence Recommended, Insufficient Evidence (I) 195 Copyright 2016 Reed Group, Ltd. Recommendation: Surgical Interventions for Failed Splinting Cases of Mallet Finger Surgery is recommended for those cases that fail splinting yet have sufficient symptoms or concerns that an attempt at fixation is desired. Strength of Evidence Recommended, Insufficient Evidence (I) Level of Confidence Moderate Rationale for Recommendation Quality studies to determine which patients with mallet finger would be optimal for surgical interventions are not currently available. A low-quality study also suggested no difference in splinting outcomes among those presenting late. Of the 9 articles considered for inclusion, 8 randomized trials and 1 systematic studies met the inclusion criteria. Author/Year Score Sample Size Comparison Group Results Conclusion Comments Study Type (0-11) O?Brien 6. The dorsal splints immobilization and graded finger splints should be blind 1b mallet finger; Vs. Clinical suggests increased lag Sponsored by (N=27) measurement overestimates true occurs after the splint is the Canadian Vs. Abouna The two splints were equally Type of splint appears 1988 males, 41 (N=58) splint: 19/58 (33%) vs 19/49 effective, producing a cure or a immaterial. Open reduction and hook Extension block pinning found fixation was higher than that of versus open reduction for No plate fixation group to be more cost-effective than extension block pinning. Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit) Diagnostic Criteria the diagnosis of flexor tendon entrapment is clinical. Patients without triggering will typically have only focal A1 pulley tenderness with or without a tendon nodule. The threshold for testing for confounding conditions such as diabetes mellitus, hypothyroidism and connective tissue disorders should be low particularly to prevent other morbidity. Splints have been used to treat trigger digits(27, 36) and they may be reasonable intervention for patients who decline injection, although it is recommended that patients be educated that the use of splints appears substantially less successful than injections (or surgery).

What it is Laboratory tests include certain blood tests pain management treatment options buy azulfidine online from canada, urinalysis deerfield beach pain treatment center cheap 500mg azulfidine free shipping, tests on tissue specimens pain medication for dogs with bad hips purchase azulfidine 500mg mastercard, and some screening tests pain treatment center utah azulfidine 500mg discount. Clinical research studies Part A and/or Part B cover some costs, like ofce visits and tests, in certain qualifying clinical research studies. Costs You may pay 20% of the Medicare-approved amount, depending on the treatment you get. What it is Clinical research studies test how well diferent types of medical care work and if they?re safe, like how well a cancer drug works. What it is Tests to help fnd precancerous growths or fnd cancer early, when treatment is most efective. Costs You pay 20% of the Medicare-approved amount for the machine rental and purchase of related supplies (like masks and tubing), and the Part B deductible applies. Medicare may cover it longer if you meet in person with your doctor, and your doctor documents in your medical record that you meet certain conditions and therapy is helping you. Medicare covers breast reconstruction if you had a mastectomy because of breast cancer. Counseling to prevent tobacco use & tobacco-caused disease Part B covers smoking and tobacco-use cessation counseling visits if your qualifed doctor or other Medicare-recognized provider provides these services. Costs You pay nothing for the counseling sessions if your doctor or other qualifed health care provider accepts assignment. Defbrillators Medicare may cover an implantable automatic defbrillator if you?ve been diagnosed with heart failure. Surgeries to implant defbrillators in the hospital inpatient setting are covered under Part A. Dental services Medicare doesn?t cover most dental care, procedures, or supplies, like cleanings, fllings, tooth extractions, dentures, dental plates, or other dental devices. Part A will pay for certain dental services that you get when you?re in a hospital. Part A can pay for hospital stays if you need to have emergency or complicated dental procedures, even though the dental care isn?t covered. Diabetes prevention program Part B covers a diabetes prevention program if all of these conditions apply to you. The program begins with 16 core sessions ofered in a group setting over a 6-month period. Support from people with similar goals Once you complete the core sessions, you?ll get. An additional 12 months of ongoing maintenance sessions if you meet certain weight loss and attendance goals Things to know To fnd a Medicare Diabetes Prevention Program supplier in your area, visit Medicare. A history of high blood sugar (glucose) Medicare also covers these screenings if 2 or more of these apply to you. Costs You pay nothing for these tests if your doctor or other qualifed health care provider accepts assignment. You may also qualify for up to 2 hours of follow-up training each year if it takes place in a calendar year afer the year you got your initial training. Costs You pay 20% of the Medicare-approved amount, and the Part B deductible applies. The program may include tips for eating healthy, being active, monitoring blood sugar, taking prescription drugs, and reducing risks. Things to know You must have a written order from your doctor or qualifed non-doctor practitioner. Some exceptions apply if group sessions aren?t available or if your doctor or qualifed non-doctor practitioner says you have special needs that would be better met by individual training sessions. Other diabetic services and supplies: See Diabetes services and Diabetes supplies on the next 2 pages. Terapeutic shoes or inserts How often Tere may be limits on how much or how ofen you get these supplies. Costs You pay 20% of the Medicare-approved amount, and the Part B deductible applies. Section 2: Items & services 31 Diabetes supplies (continued) Things to know If you have Medicare prescription drug coverage (Part D), your plan may cover insulin, certain medical supplies used to inject insulin (like syringes), and some oral diabetes drugs. Diagnostic laboratory tests Part B covers medically necessary clinical diagnostic laboratory tests, when your doctor or practitioner orders them. Costs You usually pay nothing for Medicare-covered clinical diagnostic laboratory tests. What it is Tests done to help your doctor diagnose or rule out a suspected illness or condition. Things to know Medicare also covers some preventive tests and screenings to help prevent, fnd, or manage a medical problem. You pay a copayment for diagnostic non-laboratory tests done in a hospital outpatient setting. What it is Tests done to help your doctor diagnose or rule out a suspected illness or condition. Things to know Medicare also covers some preventive tests and screenings to help prevent, fnd, or manage a medical problem. Most injectable drugs and their oral forms for outpatient or home dialysis (like an erythropoiesis-stimulating agent to treat anemia). Dialysis when you travel and use a Medicare-certifed facility Section 2: Items & services 33 Dialysis (children) (continued) Your child is eligible for Medicare if both you and your child meet these conditions: One of these conditions applies to you. You (or your spouse) have earned at least 6 credits within the last 3 years by working and paying Social Security taxes. Things to know If your child is eligible for Medicare only because of permanent kidney failure, Medicare coverage will end. Part B covers training provided during the course of your regular treatments for you and the person helping you with your self-dialysis treatments. Only dialysis facilities can bill Medicare (directly or under arrangement) for providing home dialysis training. This may include visits by trained hospital or dialysis facility workers to check on your self-dialysis, help in emergencies (when needed), and check your equipment and water supply. Covered equipment and supplies include alcohol, wipes, dialysis machines, sterile drapes, rubber gloves, and scissors. Inpatient dialysis treatments: If you have Original Medicare, Medicare pays most kidney doctors a monthly amount. Afer you pay the Part B yearly deductible, Medicare pays 80% of the monthly amount. In some cases, your doctor may be paid per day if you get services for less than one month. You pay 20% of the Medicare-approved amount for each dialysis treatment given in a dialysis facility or at home. Only dialysis facilities can bill Medicare (directly or under arrangement) for providing self-dialysis training. This means drugs taken by mouth that only come in capsule, tablet, or liquid forms. Any lost pay to you or the person who may be helping you during self-dialysis training. You pay nothing for certain preventive services if your doctor or other provider accepts assignment. Medicare also covers services provided by other health care providers, like physician assistants, nurse practitioners, clinical nurse specialists, clinical social workers, physical therapists, occupational therapists, speech language pathologists, and clinical psychologists. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren?t enrolled, Medicare won?t pay the claims they submit. If suppliers are participating suppliers, they must accept assignment (that is, they?re limited to charging you only coinsurance and the Part B deductible on the Medicare-approved amount). If suppliers are enrolled in Medicare but aren?t participating, they may choose not to accept assignment. Some equipment is rented, other equipment is purchased, and some equipment may be either rented or bought. Costs You pay 20% of the Medicare-approved amount, and the Part B deductible applies. If you have the test at a hospital or a hospital-owned clinic, you also pay the hospital a copayment.

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Sensitivity is higher in patients with triple-vessel disease and lower in patients with 2+ single-vessel disease advanced diagnostic pain treatment center order 500 mg azulfidine fast delivery. A negative stress echocardiogram is associated with an annual cardiac event rate of less than 1% xiphisternum pain treatment 500mg azulfidine. In addition to laser treatment for shingles pain order cheap azulfidine online providing information on ischaemic burden pain management for arthritis dogs cheap azulfidine 500 mg overnight delivery, it provides accurate assessment of ventricular volumes and function and identification of previous areas of myocardial infarction/scar. It does not depend on ultrasound windows and may, therefore, be useful for imaging patients who are challenging to image using stress echocardiography. Studies have demonstrated excellent diagnostic performance with a 2++ sensitivity of up to 99%,43-45 specificity of up to 92%,43-47 and a negative predictive value approaching 100%. It may also provide valuable information regarding valvular and left ventricular function. R Computerised tomography-coronary angiography should be considered for the investigation of patients with chest pain in whom the diagnosis of stable angina is suspected but not clear from history alone. R In patients with suspected stable angina, the exercise tolerance test should not be used routinely as a first-line diagnostic tool 9 Coronary angiography should be considered after non-invasive testing where patients are identified to be at high risk or where a diagnosis remains unclear. Comorbidity, for example heart failure, and other factors such as compliance and cost should be considered when selecting an individual beta blocker. Doses should be tailored individually to ensure maximum beta blockade depending on the sensitivity of the patient to specific drugs. A resting heart rate of less than 60 beats per minute is an indication of beta blockade. Meta-analyses have indicated that nifedipine monotherapy or short-acting nifedipine in combination with other antianginal 1++ drugs may increase the incidence of cardiovascular events, mainly angina episodes. It is caused by narrowing or occlusion of proximal coronary arteries due to spasm and cannot be 1+ diagnosed by coronary angiography. Beta blockers should not be used in this form of angina because they may + 2 worsen the coronary spasm. Nitrate tolerance can be avoided by prescribing modified-release long-acting preparations or by asymmetric dosing. Adherence has been shown to improve when transferring from multiple-dose 4 regimens to once-daily regimens. The sensitivity analysis showed that the result is highly sensitive to changes in the assumed adherence rates and drug costs. In current clinical practice in Scotland, prescription of a generic drug for the two-dose regimen would be cost saving (? There are few studies on the efficacy of nicorandil in the treatment and prevention of chest pain. In a double-blind randomised parallel-group trial ivabradine was shown to have equivalent antianginal efficacy to atenolol in patients with stable angina. A prespecified subgroup analysis of 12,049 participants who had symptomatic angina demonstrated a small but significant increase in the combined risk of cardiovascular death or non-fatal heart attack with ivabradine compared with placebo (3. There + 1 was benefit in terms of a reduction in symptoms and use of sublingual nitrate. The review did not address the effect of ranolazine on frequency of cardiovascular events. R Sublingual glyceryl trinitrate tablets or spray should be used for the immediate relief of angina and before performing activities that are known to bring on angina. R Beta blockers should be used as first-line therapy for the relief of symptoms of stable angina. R Rate-limiting calcium channel blockers should be considered where beta blockers are contraindicated. R Patients with Prinzmetal (vasospastic) angina should be treated with a dihydropyridine derivative calcium channel blocker, eg (amlodipine, nifedipine). Adding nicorandil to other antianginal drugs was effective in reducing combined 1++ 1+ cardiac events. In real life situations patients are usually given a second or a third antianginal drug when they become refractory to one or two drugs. More randomised trials are needed to test the efficacy of perscribing a third antianginal drug to patients whose angina is not optimally controlled on a combination of two drugs. Enteric coated products do not prevent the major gastrointestinal complications of aspirin therapy and are 1++ 95-97 2++ significantly more expensive than the standard dispersible formulation. There was a significant reduction in all ++ 1 cause and coronary mortality, myocardial infarction, the need for coronary revascularisation and fatal or non-fatal stroke. It showed that ramipril was associated with significant reductions in all-cause mortality, myocardial infarction and stroke in these patients. Subgroup analysis of the trial showed that benefit from perindopril is mainly in patients with history of myocardial infarction. R All patients with stable angina should be considered for treatment with angiotensin-converting enzyme inhibitors. This level of adherence is very likely to have a negative impact on symptom control and prognosis and limits extrapolation from clinical trials where adherence is often tightly controlled. Only five of the 17 highest-quality trials reported improvements in both adherence and clinical outcomes. Effects were generally small, and it was not possible to identify common beneficial components. The right and left coronary arteries arise from their respective coronary ostia just above the aortic valve. The right coronary artery supplies the right side of the heart and typically terminates as the posterior descending coronary artery supplying the diaphragmatic (inferior) surface of the left ventricle. The left coronary artery branches supply the anterior and lateral walls of the left ventricle and the majority of the septum. The principal indications for revascularisation are symptomatic relief and prognostic gain (increased life expectancy). The benefit is greatest in patients with left ventricular dysfunction and/or evidence of reversible ischaemia at low or moderate workloads on exercise testing. Drug-eluting balloons have been developed to reduce restenosis rates whilst avoiding stent implantation, for example in small calibre vessels, or instent restenosis (see section 5. In patients with stable angina, this symptomatic benefit lasts for up to 24 months and is greatest in patients 1+ with more severe angina. In a network meta-analysis examining 126 trials 20 | Management of stable angina 5. Interventional cardiology and cardiac surgery including 106,427 patients followed up for between six months and five years (mean 2. R In patients with stable angina undergoing percutaneous coronary intervention, second or third generation drug-eluting stent should be used unless there is a contraindication to prolonged dual antiplatelet therapy. It is a major surgical procedure with a low mortality that involves bypassing of a section of coronary artery narrowed by atheroma with a section of healthy saphenous vein or internal mammary artery. There was no difference in overall mortality, possibly due to the small sample size. Although considered minimally invasive, the procedure still involves a chest incision. Minimally invasive direct coronary bypass surgery attempts to reduce the major skin incision but its use is not widespread. The use of off-pump surgical techniques developed, in part, as a method of reducing potential cognitive impairment after surgery (see section 5. Age did not + 1 predict decline in cognitive function although the patients tended to be relatively young (in their sixties). Some studies have noted an increased rate of stenosis of radial artery grafts and have cautioned on their applicability in 3 target vessels with only moderate stenosis. Total arterial revascularisation may confer long-term benefit but application of the radial artery graft to subcritical stenoses may not confer benefit. R In patients undergoing multiple coronary artery bypass grafting, use of both internal mammary arteries should be considered. The relatively early follow-up period used may overestimate the longer-term severity of the problem. In the context of stable angina where any intervention is essentially elective, adequate time should be allocated to allow appropriate clinical decision making and fully informed decision making with the patient.