young adults. It is most often a result of hemolytic streptococcal  infection  and  is  the  most  common precursor  to  heart  disease  in  people  under  the  age of 50. Repeated attacks lead to chronic rheumatic heart  disease  thay  may  cause  mitral  or  aortic stenosis  or  insufficiency. SYMPTOMS—Normally  there  is  a  history  of URI within the last 3 weeks. Fever, tachycardia, rapid  respiration,  joint  pain,  and  swelling are common. The sedimentation rate is markedly increased,  and  the  patient  may  suffer  frequent epistaxis.   There   may   be   precordial   or   ab- dominal   pain,   malaise,   anorexia,   chores (involuntary  muscle  tics  or  jerking),  and diaphoresis. TREATMENT—General  measures  consist  of bed  rest,  aspirin,  high  caloric  soft  diet,  and support  and  protection  for  the  affected  joints. Use  penicillin  to  combat  existing  infections. Order   bed   rest   until   the   acute   stages   of   the disease  have  passed.  Return  to  full  activity may  take  months. Angina Peetoris It  is  a  characteristic,  usually  substernal, thoracic  pain  caused  by  a  mild  coronary  in- sufficiency   (normally   arteriosclerotic   heart disease) and is precipitated by exertion. Attacks are  frequently  experienced  when  mounting  inclines or  stairways.  Angina  always  occurs  during exertion  and  subsides  promptly  if  the  patient stands   or   sits   quietly.   The   patient   will usually  prefer  to  stand  or  sit  rather  than  to  lie down. SYMPTOMS—Chest  pain  is  the  chief  com- plaint. Usually it is located behind or slightly to the left of the sternum and frequently radiates to the left shoulder and arm. Occasionally the pain may be located at the base of the neck, lower jaw, axilla, or epigastrium. Rarely is it referred to the right  side  of  the  body.  The  pain  is  usually described  as  squeezing,  crushing,  or  viselike  as opposed  to  sharp  or  stabbing.  The  intensity  varies from  mild  to  severe  and  may  be  incapacitating. Episodes normally last from 1 to 3 minutes. The patient  may  experience  palpation,  faintness, sweating,  dyspnea,  and  digestive  disturbances. TREATMENT—Rest!   Nitroglycerine   is   the drug  of  choice. Amyl   nitrite   is   sometimes used. Atherosclerosis (Hardening of the Arteries) This  is  the  most  serious  form  of  arterio- sclerosis   because   of   its   tendency   to   affect coronary,  cerebral,  and  peripheral  arteries. TREATMENT—Because   of   its   insidious nature,  the  best  treatment  is  prevention.  Tech- niques  of  prevention  and  management  include treating  the  underlying  cause,  weight  reduc- tion,   exercise, discontinuance   of   smoking habits,  and  reducing  the  fat  and  cholesterol intake. Myocardial Infarction (MI) Damage  to  a  portion  of  the  heart  muscle  is caused  by  myocardial  ischemia.  It  is  most  often caused  by  blockage  of  one  or  more  of  the branches  of  the  coronary  arteries. SYMPTOMS—This  disease  may  be  preceded by  a  history  of  angina,  and  the  symptoms  may begin at any time. The major complaint is severe squeezing   or   crushing   substernal   pain.   The location  of  the  pain  is  similar  to  angina,  but is markedly more persistent. It does not subside with rest. Dyspnea, severe anxiety, and shock are common. TREATMENT—The  primary  objective  of treatment  is  to  minimize  heart  damage  and  to sustain  life.  If  the  MI  causes  cardiac/pulmonary arrest,   CPR   is   of   primary   importance.   The patient   should   be   administered   Demerol^® or morphine for pain and to help relieve apprehen- sion.  Oxygen  therapy  is  essential  and  sedation is  appropriate.  In  all  cases,  transfer  the  patient to   the   cardiac   care   unit   (CCU)   as   soon   as possible. Congestive Heart Failure This condition is due to the failure of the heart to  maintain  an  adequate  flow  of  blood  to  the tissues.  The  pulmonary  or  systemic  circulation becomes    congested, often  resulting  in  left ventricular  failure. SYMPTOMS—The  patient’s  chief  complaint is  dyspnea  and  often  a  gradual  loss  of  energy. The  ankles  are  often  swollen  and  markedly edematous.  The  blood  pressure  may  or  may  not  be increased. 2-15