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Fasting hypoglycemia Hyperinsulinism Pancreatic B cell tumor Surreptitious administration of insulin or sulfonylureas Extrapancreatic tumors Postprandial (reactive) hypoglycemia Early hypoglycemia (alimentary) Postgastrectomy Functional (increased vagal tone) Late hypoglycemia (occult diabetes) Delayed insulin release due to B cell dysfunction Counterregulatory hormone and neurogenic autonomic response deficiency Idiopathic Alcohol-related hypoglycemia Immunopathologic hypoglycemia Idiopathic anti-insulin antibodies (which release their bound insulin) Antibodies to insulin receptors (which act as agonists) Drug-induced hypoglycemia

Postinfarction management should begin with identification and modification of risk factors Treatment of hyperlipidemia and smoking cessation both prevent recurrent infarction and death LDL cholesterol levels should be lowered below 100 mg/dL, and probably to a goal of 70 mg/dL, with a statin commencing prior to discharge BP control and cardiac rehabilitation or exercise are also recommended -Blockers improve survival rates, primarily by reducing the incidence of sudden death in high-risk subsets of patients, though their value may be less in patients without complications with small infarctions and normal exercise tests While a variety of -blockers have been shown to be beneficial, for patients with LV dysfunction managed with contemporary treatment, carvedilol has been shown to reduce mortality Blockers with intrinsic sympathomimetic activity have not proved beneficial in postinfarction patients Antiplatelet agents are beneficial; aspirin (81 325 mg daily) is recommended, and adding clopidogrel (75 mg daily) has been shown to provide additional benefit short term after ST-segment elevation myocardial infarction and for up to 1 year after non-ST elevation acute coronary syndromes Warfarin anticoagulation for 3 months reduces the incidence of arterial emboli after large anterior infarctions, and according to the results of at least one study it improves long-term prognosis An advantage to combining low-dose aspirin and warfarin has not been demonstrated, except perhaps in patients with atrial fibrillation Calcium channel blockers have not been shown to improve prognoses overall and should not be prescribed

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Postinfarction patients not treated with primary PCI who appear likely to benefit from early revascularization if the anatomy is appropriate are (1) those who have undergone thrombolytic therapy and have residual symptoms or laboratory evidence of ischemia; (2) patients with LV dysfunction (EF < 30 40%) and evidence of ischemia; (3) patients with non ST elevation MI and high-risk features; and (4) patients with markedly positive exercise tests and multivessel disease The value of revascularization in the following groups is less clear: (1) patients treated with thrombolytic agents, with little evidence of reperfusion or residual ischemia; (2) patients with LV dysfunction but no detectable ischemia; and (3) patients with preserved LV function who have mild ischemia and are not symptom limited In general, patients who survive infarctions without complications, have preserved LV function (EF > 50%), and have no exercise-induced ischemia have an excellent prognosis and do not require invasive evaluation

Ades PA Cardiac rehabilitation and secondary prevention of coronary heart disease N Engl J Med 2001 Sep 20;345(12): 892 902 [PMID: 11565523]

Dagenais GR et al Angiotensin-converting-enzyme inhibitors in stable vascular disease without left ventricular systolic dysfunction or heart failure: a combined analysis of three trials Lancet 2006 Aug 12;368(9535):581 8 [PMID: 16905022] Dargie HJ et al Effect of carvedilol on outcome after myocardial infarction in patients with left ventricular dysfunction: the CAPRICORN randomized trial Lancet 2001 May 5;357 (9266):1385 90 [PMID: 11356434] Hurlen M et al Warfarin, aspirin, or both after myocardial infarction N Engl J Med 2002 Sep 26;347(13):969 74 [PMID: 12324552] Sutton MG et al Left ventricular remodeling after myocardial infarction: pathophysiology and therapy Circulation 2000 Jun 27;101(25):2981 8 [PMID: 10869273]

and in some cases flecainide, or radiofrequency modification of the sinus node have shown to have varying success in treating this problem

Still AM et al Prevalence, characteristics and natural course of inappropriate sinus tachycardia Europace 2005 Mar;7(2): 104 12 [PMID: 15763524] Yusuf S et al Deciphering the sinus tachycardias Clin Cardiol 2005 Jun;28(6):267 76 [PMID: 16028460]

ATRIAL PREMATURE BEATS (ATRIAL EXTRASYSTOLES)

Atrial premature beats occur when an ectopic focus in the atria fires before the next sinus node impulse or a reentry circuit is established The contour of the P wave usually differs from the patient s normal complex, unless the ectopic focus is near the sinus node The subsequent RR cycle length is usually unchanged or only slightly prolonged Such premature beats occur frequently in normal hearts Acceleration of the heart rate by any means usually abolishes most premature beats Early atrial premature beats may cause aberrant QRS complexes (wide and bizarre) or may be nonconducted to the ventricles because the AV node or ventricles are still refractory

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