Practical Cardiovascular Medicine. Edition No. 2

Table of Contents

Preface xx

Abbreviations xxi

About the Companion Website xxiv

Part 1. Coronary Artery Disease 1

1. Non- ST- Segment Elevation Acute Coronary Syndrome 1

I. Definition types of myocardial infarction and pitfalls 1

II. Clinical features ECG cardiac biomarkers and echocardiography in ACS 6

III. Initial approach to acute chest pain presentations and the use of conventional and high- sensitivity troponins 8

IV. Management of NSTEMI 10

V. General procedural management after coronary angiography: PCI CABG or medical therapy only 14

VI. Discharge medications in NSTEMI 14

VII. Prognosis 17

Appendix 1. Complex angiographic disease- Moderate disease progression 17

Appendix 2. Women and ACS elderly patients and ACS CKD 18

Appendix 3. Bleeding transfusion patients on chronic warfarin or NOAC gastrointestinal bleed 19

Appendix 4. Antiplatelet and anticoagulant therapy 20

Appendix 5. Difference between plaque rupture and plaque erosion 23

Appendix 6. Spontaneous coronary artery dissection 23

Appendix 7. Harmful effects of NSAIDs and cyclooxygenase- 2 inhibitors in CAD 25

Appendix 8. Additional ideas on the physiology of hs- troponin- Role of hs- troponin in primary prevention 25

Questions and answers 25

2. ST- Segment Elevation Myocardial Infarction 38

1. Definition reperfusion and general management 39

I. Definition 39

II. Timing of reperfusion 39

III. ECG phases of STEMI 40

2. Stemi Complications 50

I. Cardiogenic shock 50

II. Mechanical complications 53

III. Recurrent infarction and ischemia 55

Appendix 1. Out- of- hospital cardiac arrest: role of early coronary angiography and therapeutic hypothermia 60

Questions and answers 62

3. Stable Ischemic Heart Disease and Approach to Chronic Chest Pain 74

I. Causes of angina and pathophysiology of coronary flow 74

II. Diagnostic approach 75

III. Silent myocardial ischemia. Is there a role for screening asymptomatic patients and post- PCI patients? 78

Appendix 1. Notes on various surgical grafts 86

Appendix 2. Coronary vasospasm (variant angina Prinzmetal angina) 88

Appendix 3. Microvascular endothelial dysfunction 90

Appendix 4. Women with chest pain and normal coronary arteries 90

Appendix 5. Diagnostic strategy for ischemia with non- obstructed coronary arteries (INOCA) 91

Appendix 6. Myocardial bridging 91

Appendix 7. Coronary collaterals chronic total occlusion 92

Appendix 8. Hibernation stunning ischemic preconditioning 92

Questions and answers 93

Part 2. Heart Failure (Chronic and Acute Heart Failure Specific Cardiomyopathies and Pathophysiology) 103

4. Heart Failure 103

Definition Types Causes and Diagnosis of Heart Failure 104

1. Definition and types of heart failure 104

I. Heart failure is diagnosed clinically not by echocardiography 104

II. After HF is defined clinically echocardiography is used to differentiate the three major types of HF 105

III. Two additional types of HF 107

2. Causes of heart failure 107

I. Systolic HF or HF with reduced EF (HFrEF) 107

II. HF with preserved EF (HFpEF) 108

III. Right HF 110

3. Diagnostic tests 110

I. Echocardiography 110

II. BNP 111

III. ECG 112

IV. Coronary angiography and other ischemic tests 112

Chronic Treatment of Heart Failure 113

1. Treatment of systolic heart failure 113

I. Treat the underlying etiology: target BP and CAD 113

II. Value of revascularization in ischemic cardiomyopathy: STICH trial 113

2. Treatment of HFpEF 124

Acute Heart Failure and Acutely Decompensated Heart Failure 126

I. Triggers of acute decompensation 126

II. Profiles of acute HF: congestion without low cardiac output congestion with low cardiac output 127

Appendix 1. Management of isolated or predominant RV failure 135

Questions and answers 138

5. Additional Heart Failure Topics 156

1. Specific cardiomyopathies 156

I. Arrhythmia- induced cardiomyopathy 156

II. Viral myocarditis 157

2. Advanced heart failure: heart transplant and ventricular assist devices 163

I. Stages of HF 163

II. Cardiac transplantation 163

3. Pathophysiology of heart failure and hemodynamic aspects 166

I. LV diastolic pressure in normal conditions and in HF (whether systolic or diastolic) 166

II. Definition of afterload 167

Questions and answers 173

Part 3. Valvular Disorders 181

6. Valvular Disorders 181

1. Mitral regurgitation 182

I. Mechanisms of mitral regurgitation 182

II. Specifics of various causes of mitral regurgitation 182

2. Mitral stenosis 192

I. Etiology and natural history 192

II. Diagnosis 193

III. Treatment 197

3. Aortic insufficiency 199

I. Etiology 199

II. Pathophysiology and hemodynamics 200

III. Diagnosis 200

4. Aortic stenosis 203

I. Etiology 203

II. Echo and catheterization diagnosis pitfalls and hemodynamics 204

5. Tricuspid regurgitation and stenosis 213

I. Etiology of tricuspid regurgitation 213

II. Natural history of TR 215

6. Pulmonic stenosis and regurgitation 216

I. Pulmonic stenosis 216

II. Pulmonic regurgitation 216

7. Mixed valvular disease; radiation heart disease 217

I. Mixed single- valve disease 217

II. Multiple valvular involvement (combined stenosis or regurgitation of two different valves) 217

III. Radiation heart disease 217

8. Prosthetic valves 218

I. Bioprosthesis versus mechanical prosthesis 218

II. Determinants of valve degeneration and valve thrombosis; anticoagulation guidelines 218

III. Particular cases: women who wish to become pregnant and dialysis patients 220

IV. Echocardiographic follow- up of prosthetic valves 221

V. Complications 221

9. Auscultation and summary ideas 223

I. Auscultation and other physical findings 223

II. General ideas and workup 226

Questions and answers 227

Part 4. Hypertrophic Cardiomyopathy 243

7. Hypertrophic Cardiomyopathy 243

I. Definition and features of HCM 243

II. Natural history and mortality 245

III. Symptoms and ECG 246

Questions and answers 253

Part 5. Arrhythmias and Electrophysiology 257

8. Approach to Narrow and Wide QRS Complex Tachyarrhythmias 257

I. The unstable patient 257

II. Initial approach to any tachycardia 257

9. Ventricular Arrhythmias: Types and Management Sudden Cardiac Death 274

I. Premature ventricular complexes 274

II. Ventricular tachycardia 276

III. Polymorphic ventricular tachycardia 278

Questions and answers 288

10. Atrial Fibrillation 294

I. Predisposing factors 294

II. Types of AF 295

III. General therapy of AF 295

X. AF burden as a correlate and a driver of HF progression 303

Appendix 1. Optimal heart rate and AF rate for optimal cardiac output 303

Appendix 2. Antiarrhythmic drug therapy 303

Appendix 3. Catheter ablation of atrial fibrillation surgical ablation AV nodal ablation 305

Appendix 4. INR follow- up in patients receiving warfarin- Non- vitamin K oral anticoagulants 306

Appendix 5. Bridging anticoagulation in patients undergoing procedures 308

Appendix 6. Management of elevated INR values 309

Appendix 7. Left atrial appendage surgical and percutaneous closure 309

Appendix 8. A common situation: AF and symptomatic pauses or bradycardia 309

Appendix 9. DC cardioversion in patients with a slow ventricular response 310

Appendix 10. AF occurring post- cardiac surgery and AF related to acute transient triggers 310

Appendix 11. Brief asymptomatic runs of AF on device interrogation and association with stroke. Role of rhythm monitoring after cryptogenic stroke 310

Questions and answers 311

11. Atrial Flutter and Atrial Tachycardia 319

I. Atrial flutter 319

II. Focal atrial tachycardia 322

III. Multifocal atrial tachycardia (MAT) (or chaotic atrial tachycardia) 325

Questions and answers 326

12. Atrioventricular Nodal Reentrant Tachycardia Atrioventricular Reciprocating Tachycardia Wolff-Parkinson- White Syndrome and Junctional Rhythms 329

I. Inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS) 329

II. Atrioventricular nodal reentrant tachycardia (AVNRT) 329

III. Atrioventricular reciprocating tachycardia (AVRT) and Wolff-Parkinson-White (WPW) syndrome 332

Questions and answers 342

13. Bradyarrhythmias 345

I. AV block 345

II. Sinus node dysfunction 354

Questions and answers 359

14. Permanent Pacemaker and Implantable Cardioverter Defibrillator 363

I. Indications for permanent pacemaker implantation 363

II. Types of cardiac rhythm devices 363

Appendix. Cases of PM troubleshooting 381

Questions and answers 386

15. Basic Electrophysiologic Study 390

I. General concepts; intracardiac electrograms 390

II. AV conduction abnormalities 390

16. Action Potential Features and Propagation: Mechanisms of Arrhythmias Antiarrhythmic Drugs 403

I. Action potential 403

II. Action potential propagation and mechanisms of arrhythmias 403

Part 6. Pericardial Disorders 411

17. Pericardial Disorders 411

1. Acute pericarditis 412

I. Causes of acute pericarditis 412

II. History and physical findings 412

2. Tamponade 414

I. Definition 414

II. Pathophysiology and hemodynamics 414

3. Pericardial effusion 417

I. Causes of a pericardial effusion with or without tamponade 417

II. Management of asymptomatic effusions and role of pericardiocentesis 418

4. Constrictive pericarditis 421

I. Causes 421

II. Pathophysiology and hemodynamics 421

Questions and answers 429

Part 7. Congenital Heart Disease 435

18. Congenital Heart Disease 435

1. Acyanotic congenital heart disease 435

I. Atrial septal defect (ASD) 435

II. Patent foramen ovale (PFO) 439

2. Cyanotic congenital heart disease 444

I. Pulmonary hypertension secondary to shunt 444

II. Tetralogy of Fallot 445

3. More complex cyanotic congenital heart disease and shunt procedures 447

I. Functionally single ventricle and Fontan procedure 447

II. Transposition of great arteries (TGA) 449

Questions and answers 452

Part 8. Peripheral Arterial Disease 457

19. Peripheral Arterial Disease 457

1. Lower extremity peripheral arterial disease 457

I. Clinical tips 458

II. Clinical classification of PAD: critical limb ischemia acute limb ischemia atheroembolization 459

2. Carotid disease 466

I. Assessment of carotid stenosis 466

II. Medical therapy of carotid stenosis 467

3. Renal artery stenosis 469

I. Forms of renal artery stenosis 469

II. Screening and indications to revascularize renal artery stenosis 469

III. Notes 470

Questions and answers 470

20. Aortic Diseases 476

I. Aortic dissection 476

II. Thoracic aortic aneurysm 480

III. Abdominal aortic aneurysm 484

Part 9. Other Cardiovascular Disease States 487

21. Pulmonary Embolism and Deep Vein Thrombosis 487

1. Pulmonary embolism 487

I. Presentation of pulmonary embolism and risk factors 487

II. Probability of PE 488

III. Initial workup 488

2. Deep vein thrombosis 494

I. Types 494

II. Diagnosis 494

3. Immune heparin- induced thrombocytopenia 494

I. Incidence 495

II. Diagnosis 495

Questions and answers 495

22. Shock and Fluid Responsiveness 499

1. Shock 499

I. Shock definition and mechanisms 499

II. Goals of shock treatment 500

2. Fluid Responsiveness 503

Appendix. Hemodynamic equations transfusion and miscellaneous concepts 505

Questions and answers 507

23. Hypertension 511

1. Hypertension 511

I. Definition 511

II. ACC and ESC targets of therapy and rationale 512

2. Acute severe hypertension: hypertensive emergencies and urgencies 521

I. Definitions 521

II. Treatment of hypertensive emergencies 521

Questions and answers 523

24. Dyslipidemia 529

I. Indications for therapy 529

II. Notes on LDL HDL and triglycerides 530

Questions and answers 534

25. Pulmonary Hypertension 538

I. Definition 538

II. Categories of PH 538

Questions and answers 543

26. Syncope 547

I. Neurally mediated syncope (reflex syncope) 547

II. Orthostatic hypotension and postural orthostatic tachycardia syndrome 548

III. Cardiac syncope 549

Questions and answers 556

27. Chest Pain Dyspnea Palpitations 561

1. Chest Pain 561

I. Causes 561

II. Features 562

2. Acute Dyspnea 564

I. Causes 564

II. Notes 565

III. Management 566

3. Palpitations 567

I. Causes 567

II. Diagnosis 567

28. Infective Endocarditis and Cardiac Rhythm Device Infections 570

1. Infective endocarditis 570

I. Clinical diagnosis 570

II. Echocardiography: timing and indications 570

III. Organisms 571

2. Cardiac rhythm device infections 574

I. Organisms and mechanisms of infection 574

II. Diagnosis 574

29. Preoperative Cardiac Evaluation 577

I. Steps in preoperative evaluation 578

II. Surgical risk: surgery’s risk and patient’s risk 578

III. CARP and DECREASE V trials 579

Questions and answers 581

30. Miscellaneous Cardiac Topics: Cardiac Masses and Tumors Pregnancy HIV and Heart Disease Cocaine and the Heart Chemotherapy and Heart Disease Chest X‐Ray 584

1. Cardiac masses 585

I. Differential diagnosis of a cardiac mass 585

II. Cardiac tumors; focus on atrial myxoma 585

2. Pregnancy and heart disease 586

I. High‐risk cardiac conditions during which pregnancy is better avoided 587

II. Cardiac conditions that are usually well tolerated during pregnancy but in which careful cardiac evaluation and clinical and echo follow‐up are warranted 587

3. HIV and heart disease 590

I. Pericardial disease 590

4. Cocaine and the heart 590

I. Myocardial ischemia 590

II. Other cardiac complications of cocaine 591

5. Chemotherapy and heart disease 591

I. Cardiomyopathy 591

II. Myocardial ischemia 592

6. Chest X‐ray 593

I. Chest X‐ray in heart failure 593

II. Various forms of cardiomegaly 594

Questions and answers 596

Part 10. Cardiac Tests: Electrocardiography Echocardiography and Stress Testing 601

31. Electrocardiography 601

I. Overview of ECG leads and QRS morphology 601

II. Stepwise approach to ECG interpretation 604

III. Rhythm and rate 605

Appendix 1. Supplement on STEMI and Q‐wave MI: phases and localization 653

Appendix 2. Spread of electrical depolarization in various disease states using vector illustration 658

Questions and answers 659

32. Echocardiography 666

1. General echocardiography 666

I. The five major echocardiographic views and the myocardial wall segments 666

II. Global echo assessment of cardiac function and structure 666

III. Doppler and assessment of valvular regurgitation and stenosis 676

2. Transesophageal echocardiography (TEE) views 703

Appendix. Note on LV mechanics and myocardial tissue strain 713

33. Stress Testing Nuclear Imaging Coronary CT Angiography cardiac MRI cardiopulmonary exercise testing 714

I. Indications for stress testing 714

II. Contraindications to all stress testing modalities 715

III. Stress testing modalities 715

Part 11 Cardiac Tests: Invasive Coronary and Cardiac Procedures 733

34. Angiographic Views: Coronary Arteries and Grafts Left Ventricle Aorta Coronary Anomalies Peripheral Arteries Carotid Arteries 733

I. Right coronary artery 733

II. Left coronary artery 734

III. Coronary angiography views. Recognize the angle of a view: LAO vs. RAO cranial vs. caudal 735

Questions and answers 765

35. Cardiac Catheterization Techniques Tips and Tricks 768

I. View for the engagement of the native coronary arteries: RAO vs. LAO 768

II. Design of the Judkins and Amplatz catheters 768

III. Engagement of the RCA 768

36. Hemodynamics 790

I. Right heart catheter 790

II. Overview of pressure tracings: differences between atrial ventricular and arterial tracings 790

III. RA pressure abnormalities 790

Appendix 1. Advanced hemodynamic calculation: a case of shunt with pulmonary hypertension 808

Questions and answers: Additional hemodynamic cases 809

37. Intracoronary Imaging 815

1. Intravascular ultrasound (IVUS) 815

I. Image basics 815

II. Plaque types 818

2. Optical coherence tomography (OCT) 823

38. Percutaneous Coronary Interventions and Complications Intra‐Aortic Balloon Pump Ventricular Assist Devices and Fractional Flow Reserve 826

I. Major coronary interventional devices 826

II. Stent thrombosis restenosis and neoatherosclerosis 828

III. Peri‐PCI antithrombotic therapy 830

Questions and answers 845

Appendix: General review questions 851

1. Questions 851

I. NSTEMI and STEMI 851

II. Stable CAD 855

III. Heart failure and cardiomyopathies 858

2. Answers 901

Index 931

Authors

Elias B. Hanna Louisiana State University School of Medicine, New Orleans, LA, USA.