The incidence of perforation, while low, is increased with new devices. Women and the elderly are at highest risk. The clinical risk after perforation can be classified angiographically, but even low-risk perforations occasionally have poor clinical outcome. Patients should be observed for delayed cardiac tamponade for at least 24 hours.

Hypertension accounts for 1 in 5 deaths among American women, posing a greater burden for women than men, and is among their most important risk factors for death and development of cardiovascular and other diseases. Hypertension affects women in all phases of life, with specific characteristics relating to risk factors and management for primary prevention of hypertension in teenage and young adult women; hypertension in pregnancy; hypertension during use of oral contraceptives and assisted reproductive technologies, lactation, menopause, or hormone replacement; hypertension in elderly women; and issues of race and ethnicity. All are detailed in this review, as is information relative to women in clinical trials of hypertension and medication issues. The overarching message is that effective treatment and control of hypertension improves cardiovascular outcomes. But many knowledge gaps persist, including the contribution of hypertensive disorders of pregnancy to cardiovascular disease risk, the role of hormone replacement, blood pressure targets for elderly women, and so on.

The need for prophylactic anticoagulation to prevent embolism before direct current cardioversion is performed for atrial fibrillation or atrial flutter is controversial. To examine this issue further, a retrospective review was undertaken to assess the incidence of embolic complications after cardioversion. The review involved 454 elective direct current cardioversions performed for atrial fibrillation or atrial flutter over a 7 year period. The incidence rate of embolic complications was 1.32% (six patients); the complications ranged from minor visual disturbances to a fatal cerebrovascular event. All six patients had atrial fibrillation, and none had been on anticoagulant therapy (p = 0.026). The duration of atrial fibrillation was less than 1 week in five of the six patients who had embolic complications. Baseline characteristics of patients with a postcardioversion embolic event are compared with those of patients who did not have an embolic event. There was no difference in the prevalence of hypertension, diabetes mellitus or prior stroke between the two groups, and there was no difference in the number of patients who were postoperative or had poor left ventricular function. Left atrial size was similar between the two groups. No patient in the embolic group had valvular disease. No patient with atrial flutter had an embolic event regardless of anticoagulant status; therefore, anticoagulation is not recommended for patients with atrial flutter undergoing cardioversion. Prophylactic anticoagulation is pivotal in patients undergoing elective direct current cardioversion for atrial fibrillation, even those with atrial fibrillation of less than 1 week's duration.

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