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Common adverse effects of nitrates include postural hypotension, dizziness, flushing, and headache secondary to venodilation. Headache often resolves with continued therapy and may be treated with acetaminophen. Hypotension is generally of no serious consequence. However, in patients with hypertrophic obstructive cardiomyopathy or severe aortic valve stenosis, nitroglycerin may cause serious hypotension and syncope. Therefore, long-acting nitrates are relatively contraindicated in these conditions. Because life-threatening hypotension may occur with concomitant use of nitrates and phosphodiesterase type 5 inhibitors, nitrates should not be used within 24 hours of taking sildenafil or vardenafil or within 48 hours of taking tadalafil. Skin erythema and inflammation may occur with transdermal nitroglycerin administration and may be minimized by rotating the application site. Ranolazine  ranolazine is an anti-ischemic agent indicated for the management of chronic angina. The mechanism of action is unclear, but it is believed to inhibit the late inward sodium current during the plateau phase of the cardiac action potential. Under ischemic conditions, excess sodium may enter the myocardial cell during systole. The resultant intracellular sodium overload leads to intracellular calcium accumulation (calcium overload) through a sodium/calcium exchange mechanism. Calcium overload results in increases in left ventricular wall tension and myocardial oxygen consumption. By reducing intracellular sodium concentrations in ischemic myocytes, ranolazine decreases intracellular calcium overload, left ventricular wall tension, and myocardial oxygen consumption. Similar to other antianginal drugs, ranolazine reduces angina and increases exercise capacity but does not reduce incidence of mace. Ranolazine has minimal effects on heart rate or bp. Thus, it may be an option in ihd patients with low baseline bp or heart rate.

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~ ~ongolianspob 1. Benign pigmented lesions found in 70% to 90% of black, hispanic, and asian infants. The lesions may be small or large, grayish blue or bluish black in color. 2. Caused by the increased presence of melanocytes, most commonly found in the lumbosacral region. B. Cafe au lait spob 1. Flat, brown, round, or oval lesions with smooth edges occurring in 10% of normal infants. 2. Usually oflittle or no significance but may indicate neurofibromatosis iflarger than 4 to 6 em or >6 are present. C. Albinism. Most commonly an autosomal recessive condition involving abnormal melanin synthesis leading to a deficiency in pigment production. The only effective treatment is protection from light. 838 i skin care d. Piebaldism (partial albinism). Autosomal dominant disorder present at birth characterized by off-white macules (depigmented lesions with hyperpigmented borders) on the scalp and forehead and on the trunk and extremities. The hair may be involved as well. A white "forelock," as in waardenburg syndrome, is a feature of this disorder. E. Junctional nevi. Brown or black, flat or slightly raised lesions present at birth occurring at the junction of the dermis and epidermis. They are benign lesions requiring no treatment.

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2008;118(16):1626–1636. 136  section 1  |  cardiovascular disorders 29. James s, angiolillo dj, cornel jh, et al. Ticagrelor vs. Clopidogrel in patients with acute coronary syndromes and diabetes. A substudy from the platelet inhibition and patient outcomes (plato) trial. Eur heart j. 2010;31(24):3006–3016. 30. Wallentin l, james s, storey rf, et al. Effect of cyp2c19 and abcb1 single nucleotide polymorphisms on outcomes of treatment with ticagrelor versus clopidogrel for acute coronary syndromes. A genetic substudy of the plato trial. Lancet. 2010;376(9749):1320–1328. 31. Siller-matula jm, huber k, christ g, et al. Impact of clopidogrel loading dose on clinical outcome in patients undergoing percutaneous coronary intervention. A systematic review and meta-analysis. Heart. 2011;97(2):98–105. 32. Mehta sr, tanguay jf, eikelboom jw, et al. Double-dose versus standard-dose clopidogrel and high-dose versus lowdose aspirin in individuals undergoing percutaneous coronary intervention for acute coronary syndromes (current-oasis 7). A randomised factorial trial. Lancet. 2010;376(9748):1233–1243. 33. Mangalpally kk, kleiman ns. The safety of clopidogrel. Expert opin drug saf. 2011;10(1):85–95.

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Ifedtocardiography is not able to fully show these details, then diagnostic catheterization is performed. Surgical repair of the asymptomatic child with tetralogy of fallot is usually recommended within the first 6 months oflife. The symptomatic (i.E., severely cyanotic) neonate should have operative intervention. Complete repair is generally performed at our institution, although a systemic-to-pulmonary artery shwtt is sometimes employed in wtusual cases such as multiple ventrirular septal defects or coronary anomalies. 5. Ebstein anomaly (see figs. 41.10a and 41.10b) is an uncommon but grave anatomic lesion when it presents in the neonatal period. Anatomically, there is •'downward displacement" of the tricuspid valve into the body of the right ebstein anomaly a b figure 41.1 0. A. Ebstein anomaly (with large, nonrestrictive ductus arteriosus). Typical ana~ tomic and hemodynamic &.Dings include (i) inferior displacement of the tricuspid valve into the right ventricle, which may also cause subpulmonary obstruction, (ii) diminutive muscular right ventricle, (iii) marked enlargement of the right atrium due to "atrialized." portion of right ventricle as well as tricuspid regurgitation, (iv) righho-left shunting at the atrial level (note art~ rial oxygen saturation of78%), (v) a left~to-right shunt and pulmonary hypertension secondary to a large patent ductus arteriosus supplying the pulmonary blood flow. (vi) low cardiac output (note low mixed venous oxygen sanuation in the superior vena cava). B. Chest radiograph in a neonate with severe ebstein anomaly and no signilicant pulmonary blood flow from the ductus arteriosus. The cardiomegaly is due to marked dilation of the right atrium. The pulmonary vascular markings are diminished due to the decreased pulmonary blood flow. Hypoplasia of the lungs is common due to the large heart causing a "space-occupying lesion." m = mean value. 504 i cardiac disorders ventricle. The tricuspid valve is frequently regurgitant resulting in marked right atrial enlargement and a large right-to-left shunt at the atrial level. There is little forward flow out the rv outflow tract into the pulmonary circulation. The prognosis for neonates presenting with profound cyanosis due to ebstein anomaly is quite grave. Surgical options are controversial and are generally reserved for the severely symptomatic child. Further complicating the medical condition, ebstein anomaly is often associated with wolff-parkinson-white (wpw) syndrome and supraventricular tachycardia (svt). Medical management is aimed at supporting the neonate through the initial period of transitional circulation. Because of elevated pulmonary vascular resistance, pulmonary blood flow may be quite severely limited with profound hypoxemia and acidosis as a result. Medical treatment includes treatment of pulmonary hypertension with oxygen, alkalosis, and inhaled nitric oxide (ino) (see chap. 36).