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Figure 2 2 Evaluation and classification of unexplained chronic fatigue (CBC, complete blood count; ESR, erythrocyte sedimentation rate; ALT, alanine aminotransferase; Ca2+, calcium; PO43 , phosphate; BUN, blood urea nitrogen; TSH, thyroidstimulating hormone; UA, urinalysis) (Modified and reproduced, with permission, from Fukuda K et al The chronic fatigue syndrome: a comprehensive approach to its definition and study Ann Intern Med 1994 Dec 15;121(12):953 9) associated with a high prevalence of fatigue, including CHF, COPD, arthritis, and cancer Psychostimulants such as methylphenidate have shown inconsistent results in randomized trials of treatment of cancer-related fatigue logic treatment emphasizing self-help and aiming to change perceptions and behaviors that may perpetuate symptoms and disability, is helpful Although few patients are cured, the treatment effect is substantial Response to cognitive-behavioral therapy is not predictable on the basis of severity or duration of chronic fatigue syndrome, although patients with low interest in psychotherapy rarely benefit Graded exercise has also been shown to improve functional work capacity and physical function At present, intensive individual cognitivebehavioral therapy administered by a skilled therapist and graded exercise are the treatments of choice for patients with chronic fatigue syndrome In addition, the clinician s sympathetic listening and explanatory responses can help overcome the patient s frustrations and debilitation by this still mysterious illness All patients should be encouraged to engage in normal activities to the extent possible and should be reassured that full recovery is eventually possible in most cases

A variety of agents and modalities have been tried for the treatment of chronic fatigue syndrome Acyclovir, intravenous immunoglobulin, nystatin, and low-dose hydrocortisone/fludrocortisone do not improve symptoms There is a greater prevalence of past and current psychiatric diagnoses in patients with this syndrome Affective disorders are especially common, but fluoxetine alone, 20 mg daily, is not beneficial Patients with chronic fatigue syndrome have benefited from a comprehensive multidisciplinary intervention, including optimal medical management, treating any ongoing affective or anxiety disorder pharmacologically, and implementing a comprehensive cognitive-behavioral treatment program Cognitive-behavioral therapy, a form of nonpharmaco-

Table 10 4 provides a summary of the ACC/AHA Guideline recommendations for selected medical treatments

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Treatment of acute coronary syndromes without ST elevation should be multifaceted and vigorous Patients who are at high risk should be hospitalized, maintained at bed rest or at very limited activity, monitored, and given supplemental oxygen Sedation with a benzodiazepine agent may help if anxiety is present

Coronary thrombosis plays a prominent role in the pathophysiology of unstable angina and its progression to myocardial infarction, and antithrombotic therapy plays an important role in treatment Patients should receive a combination of antiplatelet and anticoagulant agents Aspirin, 81 325 mg daily, and heparin (low-molecular-weight or unfractionated) should be commenced on presentation Several trials have shown that low-molecular-weight heparin (and specifically enoxaparin 1 mg/kg subcutaneously every 12 hours) is somewhat more effective than unfractionated heparin in preventing recurrent ischemic events in the

Acute coronary syndromes comprise the spectrum of unstable cardiac ischemia from unstable angina to acute myocardial infarction Rather than the traditional nomenclature of unstable angina, non-Q wave and Q wave myocardial infarction, acute coronary syndromes are now classified based on

1:

Table 10 4 Summary of the current ACC/AHA guideline recommendations for medical management of acute coronary syndromes (ACS) and acute myocardial infarction (AMI)1

Medication Aspirin (ASA) Clopidogrel in ASA-allergic patients Clopidogrel, intended medical management Clopidogrel, early catheterization/percutaneous coronary intervention (catheterization/percutaneous coronary intervention [cath/PCI]) Heparin (unfractionated or low-molecular-weight) -Blockers Angiotensin-converting enzyme (ACE) inhibitors Glycoprotein (GP) IIb/IIIa inhibitors for intended early cath/PCI Eptifibatide/tirofiban Abciximab GP IIb/IIIa inhibitors for high-risk patients without intended early cath/PCI Eptifibatide/tirofiban Abciximab Lipid-lowering agent

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